MEDICARE: MS. KIEOLA LEE LMFT

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	106H00000X	Marriage & Family Therapist	001330	NY

General Provider Information

NPI Number	:	1578189023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIEOLA LEE LMFT

Provider Business Mailing Address
First Line	:	PO BOX 101
Second Line	:
City	:	CORAM
State	:	NY
Zip	:	11727-0101
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	116 HORIZON VIEW DR
Second Line	:
City	:	FARMINGVILLE
State	:	NY
Zip	:	11738-3039
Country	:	US
Telephone Number	:	516-380-9594
Fax Number	:

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

Provider Enumeration Date	:	06/21/2020
Last Update Date	:	06/21/2020

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