Provider Demographics
NPI:1720351620
Name:LEE, KERRY (LCSW, LADC)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-5702
Mailing Address - Country:US
Mailing Address - Phone:860-887-6536
Mailing Address - Fax:860-885-1970
Practice Address - Street 1:40 BROADWAY
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-5702
Practice Address - Country:US
Practice Address - Phone:860-887-6536
Practice Address - Fax:860-885-1970
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000817101YA0400X
CT0063531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)