Provider Demographics
NPI:1669994067
Name:LEE, PHILLIP T (LAC)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:T
Last Name:LEE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10410 MONTGOMERY AVE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-3329
Mailing Address - Country:US
Mailing Address - Phone:301-890-4055
Mailing Address - Fax:
Practice Address - Street 1:7625 MAPLE LAWN BLVD STE 155
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2598
Practice Address - Country:US
Practice Address - Phone:301-890-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02398171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist