Provider Demographics
NPI:1255940185
Name:LEE, TANYA LATRICE (MSCP, LPC)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:LATRICE
Last Name:LEE
Suffix:
Gender:F
Credentials:MSCP, LPC
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:L
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSCP, LPC
Mailing Address - Street 1:8400 W VIRGINIA AVE APT 2044
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-8377
Mailing Address - Country:US
Mailing Address - Phone:763-703-0298
Mailing Address - Fax:
Practice Address - Street 1:8400 W VIRGINIA AVE APT 2044
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-8377
Practice Address - Country:US
Practice Address - Phone:763-703-0298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OK11291101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201160590Medicaid
OK1255940185Medicaid
AZ1275355950Medicaid
OK200927670Medicaid