Provider Demographics
NPI:1851429336
Name:LEE, KATHY (MACCCSLP)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 VIRGINIA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-5577
Mailing Address - Country:US
Mailing Address - Phone:772-462-6636
Mailing Address - Fax:772-462-6635
Practice Address - Street 1:4001 VIRGINIA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-5577
Practice Address - Country:US
Practice Address - Phone:772-462-6636
Practice Address - Fax:772-462-6635
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL007565235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA2466OtherSTATE LICENSE