Provider Demographics
NPI:1023263456
Name:LEE, RUSSELL F (ED, LP)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:F
Last Name:LEE
Suffix:
Gender:M
Credentials:ED, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 15TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-2528
Mailing Address - Country:US
Mailing Address - Phone:218-751-3280
Mailing Address - Fax:218-751-3298
Practice Address - Street 1:722 15TH ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-2528
Practice Address - Country:US
Practice Address - Phone:218-751-3280
Practice Address - Fax:218-751-3298
Is Sole Proprietor?:No
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1813103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling