Healthcare Provider Details

I. General information

NPI: 1578936266
Provider Name (Legal Business Name): SHENIQUA M LEE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 BROADHOLLOW RD STE 6E
FARMINGDALE NY
11735-4830
US

IV. Provider business mailing address

68 3RD ST
BRENTWOOD NY
11717-6114
US

V. Phone/Fax

Practice location:
  • Phone: 631-664-7488
  • Fax:
Mailing address:
  • Phone: 631-335-3166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number012739
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: