Basic Information
| Provider Information | |||||||||
| NPI: | 1457905804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 S 48TH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727626683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4797504843 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 W SUNBRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727031822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796951240 | ||||||||
| FaxNumber: | 4797504843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2019 | ||||||||
| LastUpdateDate: | 07/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 8903-M | AR | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.