Provider Demographics
NPI:1134522147
Name:LEE, REBECCA JEAN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JEAN
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 1:30669 US HIGHWAY 19 N STE 409
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-4410
Mailing Address - Country:US
Mailing Address - Phone:214-868-2710
Mailing Address - Fax:
Practice Address - Street 1:30669 US HIGHWAY 19 N STE 409
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-4410
Practice Address - Country:US
Practice Address - Phone:214-868-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29-44-1498101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist