MEDICARE: DR. SUSAN J. LEE PSY.D.

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	103TC0700X	Clinical Psychologist	6759	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W06221	OTHER	MA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1295709020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN J. LEE PSY.D.

Provider Business Mailing Address
First Line	:	354 BEAVER ST
Second Line	:
City	:	WALTHAM
State	:	MA
Zip	:	02452-6232
Country	:	US
Telephone Number	:	781-696-9940
Fax Number	:	866-722-5733

Provider Business Practice Location Address
First Line	:	259 MASSACHUSETTS AVE
Second Line	:
City	:	ARLINGTON
State	:	MA
Zip	:	02474-8406
Country	:	US
Telephone Number	:	781-696-9940
Fax Number	:	866-722-5733

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

Provider Enumeration Date	:	02/16/2006
Last Update Date	:	09/15/2008

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