Healthcare Provider Details

I. General information

NPI: 1063772689
Provider Name (Legal Business Name): LEE BARROW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2012
Last Update Date: 05/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 E EDGEWOOD DR SUTIE 11
LAKELAND FL
33803-3634
US

IV. Provider business mailing address

PO BOX 1533
HIGHLAND CITY FL
33846-1533
US

V. Phone/Fax

Practice location:
  • Phone: 863-937-9152
  • Fax: 863-937-9154
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH4263
License Number StateFL

VIII. Authorized Official

Name: MICHELLE TULL
Title or Position: ADMINISTRATOR
Credential:
Phone: 863-937-9152