Provider Demographics
NPI:1871640052
Name:LEE, MARY A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
Last Name:LEE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 LINCOLN HWY
Mailing Address - Street 2:#167
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2316
Mailing Address - Country:US
Mailing Address - Phone:708-983-8030
Mailing Address - Fax:708-283-2544
Practice Address - Street 1:2555 LINCOLN HWY
Practice Address - Street 2:STE. 108C
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1936
Practice Address - Country:US
Practice Address - Phone:708-983-8030
Practice Address - Fax:708-283-2544
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004127103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK02822Medicare UPIN