Basic Information
Provider Information
NPI: 1003145160
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEE
FirstName: SHANTE
MiddleName: NICHOLE
NamePrefix: MISS
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1011 9TH ST
Address2:  
City: NEWARK
State: DE
PostalCode: 197118726
CountryCode: US
TelephoneNumber: 6108427524
FaxNumber: 6108761944
Practice Location
Address1: 1011 9TH ST
Address2:  
City: NEWARK
State: DE
PostalCode: 197118726
CountryCode: US
TelephoneNumber: 6108427524
FaxNumber: 6108761944
Other Information
ProviderEnumerationDate: 12/18/2009
LastUpdateDate: 12/18/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800X PAY Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


Home