Provider Demographics
NPI:1295709020
Name:LEE, SUSAN J (PSYD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:J
Last Name:LEE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-6232
Mailing Address - Country:US
Mailing Address - Phone:781-696-9940
Mailing Address - Fax:866-722-5733
Practice Address - Street 1:259 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474-8406
Practice Address - Country:US
Practice Address - Phone:781-696-9940
Practice Address - Fax:866-722-5733
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6759103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06221OtherBLUE CROSS BLUE SHIELD
W51164Medicare ID - Type Unspecified