Healthcare Provider Details

I. General information

NPI: 1821881905
Provider Name (Legal Business Name): EMILY MICHELLE LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E MISSISSIPPI AVE
RUSTON LA
71270-3905
US

IV. Provider business mailing address

1000 CHINABERRY DR STE 900
BOSSIER CITY LA
71111-2455
US

V. Phone/Fax

Practice location:
  • Phone: 318-202-3706
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPLC11155
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: