Healthcare Provider Details

I. General information

NPI: 1124285010
Provider Name (Legal Business Name): ELAINE IDA LEE BCBA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

S78W18425 LIONS PARK DR APT 1
MUSKEGO WI
53150-8703
US

IV. Provider business mailing address

S78W18425 LIONS PARK DR APT 1
MUSKEGO WI
53150-8703
US

V. Phone/Fax

Practice location:
  • Phone: 815-590-7466
  • Fax:
Mailing address:
  • Phone: 815-590-7466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.005691
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number67-140
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: