Provider Demographics
NPI:1912582214
Name:LEE, WINTER P
Entity Type:Individual
Prefix:
First Name:WINTER
Middle Name:P
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 1:11122 ABERDEEN ST NE UNIT G
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-6017
Mailing Address - Country:US
Mailing Address - Phone:763-528-5379
Mailing Address - Fax:
Practice Address - Street 1:3007 HARBOR LN N STE 1200
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5103
Practice Address - Country:US
Practice Address - Phone:612-445-8314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN247200000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty