Basic Information
| Provider Information | |||||||||
| NPI: | 1699308007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | WILCOSKY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 296 SUMMER ST # 1 | ||||||||
| Address2: | |||||||||
| City: | SOMERVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021443114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196360351 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12 TYLER ST | ||||||||
| Address2: | |||||||||
| City: | SOMERVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021433241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176293919 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2020 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.