Healthcare Provider Details

I. General information

NPI: 1710318134
Provider Name (Legal Business Name): KEVIN LEE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 BROADWAY
AMITYVILLE NY
11701-2790
US

IV. Provider business mailing address

191 BROADWAY
AMITYVILLE NY
11701-2790
US

V. Phone/Fax

Practice location:
  • Phone: 631-264-0058
  • Fax:
Mailing address:
  • Phone: 631-264-0058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number088663
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number090975
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: