MEDICARE: MS. BONNIE MAE LEE MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	3093-123	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144310194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BONNIE MAE LEE MSW

Provider Business Mailing Address
First Line	:	1090 S TAMIAMI TRL
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34236-9116
Country	:	US
Telephone Number	:	904-605-4986
Fax Number	:	941-460-5599

Provider Business Practice Location Address
First Line	:	2270 HOLMGREN WAY
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-4710
Country	:	US
Telephone Number	:	920-544-5294
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	12/06/2022

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