Provider Demographics
NPI:1871852699
Name:LEE-EDWARDS, DONALD R (PHD,MD,LP)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:R
Last Name:LEE-EDWARDS
Suffix:
Gender:M
Credentials:PHD,MD,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 GORDON ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1943
Mailing Address - Country:US
Mailing Address - Phone:718-554-0744
Mailing Address - Fax:206-337-9412
Practice Address - Street 1:255 GORDON ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1943
Practice Address - Country:US
Practice Address - Phone:718-554-0744
Practice Address - Fax:206-337-9412
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4053692103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1710252127OtherNPI