Provider Demographics
NPI:1982120937
Name:LEE, CHRYL SMITH
Entity Type:Individual
Prefix:
First Name:CHRYL
Middle Name:SMITH
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 1:1705 W FELICIANA AVENUE
Mailing Address - Street 2:
Mailing Address - City:TALULLAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282
Mailing Address - Country:US
Mailing Address - Phone:318-435-7715
Mailing Address - Fax:
Practice Address - Street 1:1705 W FELICIANA AVE
Practice Address - Street 2:
Practice Address - City:TALULLAH
Practice Address - State:LA
Practice Address - Zip Code:71282
Practice Address - Country:US
Practice Address - Phone:318-435-7715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA101YM0800XMedicaid