Provider Demographics
NPI:1255449302
Name:LEE, MIKE I (PY)
Entity type:Individual
Prefix:MR
First Name:MIKE
Middle Name:I
Last Name:LEE
Suffix:
Gender:M
Credentials:PY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24911
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0911
Mailing Address - Country:US
Mailing Address - Phone:206-788-3683
Mailing Address - Fax:
Practice Address - Street 1:720 8TH AVE S
Practice Address - Street 2:SUITE 100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3032
Practice Address - Country:US
Practice Address - Phone:206-788-3718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003129103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
5762LEOtherREGENCE
WA8492977Medicaid
6921LEOtherREGENCE
8864121Medicare PIN
WA8492977Medicaid