Healthcare Provider Details

I. General information

NPI: 1609287028
Provider Name (Legal Business Name): FANIA LEE PSYD HSPP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 WASHINGTON AVE
EVANSVILLE IN
47713-1317
US

IV. Provider business mailing address

43 WASHINGTON AVE
EVANSVILLE IN
47713-1317
US

V. Phone/Fax

Practice location:
  • Phone: 812-455-6597
  • Fax:
Mailing address:
  • Phone: 812-455-6597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. FANIA LEE
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PSYD HSPP
Phone: 812-455-6597