Provider Demographics
NPI:1669516514
Name:LEE, MODESTA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MODESTA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SAXON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4813
Mailing Address - Country:US
Mailing Address - Phone:718-761-7716
Mailing Address - Fax:718-477-0079
Practice Address - Street 1:11 SAXON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-4813
Practice Address - Country:US
Practice Address - Phone:718-761-7716
Practice Address - Fax:718-477-0079
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPRO0154471041C0700X
NJSC149401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01668675Medicaid
NYN4C133Medicare ID - Type UnspecifiedEMPIRE
NY01668675Medicaid