Provider Demographics
NPI:1720177975
Name:LEE, LAURA A (PT)
Entity Type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:A
Last Name:LEE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32490
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85064-2490
Mailing Address - Country:US
Mailing Address - Phone:602-230-4478
Mailing Address - Fax:602-230-9962
Practice Address - Street 1:4232 E CACTUS RD
Practice Address - Street 2:SUITE 110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-7602
Practice Address - Country:US
Practice Address - Phone:602-996-9949
Practice Address - Fax:602-996-6760
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ183586Medicaid
AZ183586Medicaid