Provider Demographics
NPI:1750904090
Name:LEE, SANDRA S
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:S
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 CRESCENZI CT
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4136
Mailing Address - Country:US
Mailing Address - Phone:862-520-5383
Mailing Address - Fax:
Practice Address - Street 1:236 CRESCENZI CT
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-4136
Practice Address - Country:US
Practice Address - Phone:862-520-5383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00250900103T00000X, 103TC0700X
103TA0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth