Provider Demographics
NPI:1972842474
Name:LEE, MISHA (MS,CCC-SLP, CALT)
Entity Type:Individual
Prefix:
First Name:MISHA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MS,CCC-SLP, CALT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-4045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 COLLEGE DR # 5214
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39406-0002
Practice Address - Country:US
Practice Address - Phone:601-266-5223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist