Basic Information
| Provider Information | |||||||||
| NPI: | 1093950727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | GAIL | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2035 COMMONWEALTH AVE | ||||||||
| Address2: | 3 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021355145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177820452 | ||||||||
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| Practice Location | |||||||||
| Address1: | 61 MEDFORD ST | ||||||||
| Address2: | |||||||||
| City: | SOMERVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021433421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176293919 | ||||||||
| FaxNumber: | 6176294644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2008 | ||||||||
| LastUpdateDate: | 12/09/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 206691 | MA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.