Healthcare Provider Details

I. General information

NPI: 1043129810
Provider Name (Legal Business Name): ALICIA RENAI LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 PARK ST APT B1
MANCHESTER CT
06040-5993
US

IV. Provider business mailing address

122 PARK ST APT B1
MANCHESTER CT
06040-5993
US

V. Phone/Fax

Practice location:
  • Phone: 334-294-3430
  • Fax: 334-294-3430
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17303
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: