Healthcare Provider Details

I. General information

NPI: 1053222356
Provider Name (Legal Business Name): EDDIE LEE II LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EVES DR STE 111
MARLTON NJ
08053-3125
US

IV. Provider business mailing address

23 WENDEE WAY
SEWELL NJ
08080-3527
US

V. Phone/Fax

Practice location:
  • Phone: 856-427-1214
  • Fax:
Mailing address:
  • Phone: 856-237-9850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00990500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: