Provider Demographics
NPI:1013314129
Name:LEE, JEANINE CONTRYELLE
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:CONTRYELLE
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9315 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1260
Mailing Address - Country:US
Mailing Address - Phone:313-443-6322
Mailing Address - Fax:313-450-4040
Practice Address - Street 1:17328 OHIO ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2575
Practice Address - Country:US
Practice Address - Phone:313-443-6322
Practice Address - Fax:313-450-4040
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014414101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health