Provider Demographics
NPI:1821693482
Name:LEE, ROBERT T II (RCSWI)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:LEE
Suffix:II
Gender:M
Credentials:RCSWI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-2603
Mailing Address - Country:US
Mailing Address - Phone:321-506-4224
Mailing Address - Fax:
Practice Address - Street 1:105 S RIVERSIDE DR STE 122
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-4321
Practice Address - Country:US
Practice Address - Phone:321-506-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW13431104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty