Provider Demographics
NPI:1811264609
Name:LEE, PHYLLIS P (MS MFT)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:P
Last Name:LEE
Suffix:
Gender:F
Credentials:MS MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 ROAD 3084
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-2839
Mailing Address - Country:US
Mailing Address - Phone:505-320-6691
Mailing Address - Fax:
Practice Address - Street 1:15 ROAD 3084
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-2839
Practice Address - Country:US
Practice Address - Phone:505-320-6691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0144671106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist