Healthcare Provider Details

I. General information

NPI: 1710252127
Provider Name (Legal Business Name): DR. DONALD R LEE-EDWARDS PH.D, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 GORDON ST
STATEN ISLAND NY
10304-1943
US

IV. Provider business mailing address

255 GORDON ST
STATEN ISLAND NY
10304-1943
US

V. Phone/Fax

Practice location:
  • Phone: 347-500-7785
  • Fax:
Mailing address:
  • Phone: 347-500-7785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number4053692
License Number StateNY

VIII. Authorized Official

Name: DONALD R LEE-EDWARDS
Title or Position: OWNER
Credential: PH.D,LP
Phone: 347-500-7785