Provider Demographics
NPI:1457415226
Name:LEE, AMY S (MA, CCC)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:S
Last Name:LEE
Suffix:
Gender:F
Credentials:MA, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1980 BIDWELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-9645
Mailing Address - Country:US
Mailing Address - Phone:530-879-9507
Mailing Address - Fax:
Practice Address - Street 1:4328 ROCHARD LN
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29707-5851
Practice Address - Country:US
Practice Address - Phone:530-518-8248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13697235Z00000X
WALL60502109235Z00000X
CASP10057235Z00000X
SC6953235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSP000510Medicaid