Provider Demographics
NPI:1790504512
Name:VAN DER LEE, SIMONE ISABEL
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:ISABEL
Last Name:VAN DER 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 1:164 WACCAMAW MEDICAL PARK DR.
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526
Mailing Address - Country:US
Mailing Address - Phone:843-347-4888
Mailing Address - Fax:
Practice Address - Street 1:164 WACCAMAW MEDICAL PARK DR.
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526
Practice Address - Country:US
Practice Address - Phone:843-347-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health