Provider Demographics
NPI:1639344633
Name:LEE, TERESA DAWN (MS CCC-SP)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:DAWN
Last Name:LEE
Suffix:
Gender:F
Credentials:MS CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:IN
Mailing Address - Zip Code:47446-6737
Mailing Address - Country:US
Mailing Address - Phone:812-583-6414
Mailing Address - Fax:812-849-5225
Practice Address - Street 1:1125 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:IN
Practice Address - Zip Code:47446-6737
Practice Address - Country:US
Practice Address - Phone:812-583-6414
Practice Address - Fax:812-849-5225
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22001291A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200861830AOtherLEGACY PROVIDER IDENTIFIER (LPI)
00211144OtherAMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION
IN22001291AOtherINDIANA PROFESSIONAL LICENSING AGENCY LICENSE NUMBER