Provider Demographics
NPI:1962638007
Name:LEE, JOHN WON (PHD, MA, MBA)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WON
Last Name:LEE
Suffix:
Gender:M
Credentials:PHD, MA, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 WATERMAN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2052
Mailing Address - Country:US
Mailing Address - Phone:401-632-0155
Mailing Address - Fax:401-632-0570
Practice Address - Street 1:124 WATERMAN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2052
Practice Address - Country:US
Practice Address - Phone:401-632-0155
Practice Address - Fax:401-632-0570
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01119103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical