Provider Demographics
NPI:1174116628
Name:LEE, MISOON SHIN
Entity type:Individual
Prefix:
First Name:MISOON
Middle Name:SHIN
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 EUDORA TRL
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-6281
Mailing Address - Country:US
Mailing Address - Phone:404-518-9414
Mailing Address - Fax:
Practice Address - Street 1:1810 PEACHTREE INDUSTRIAL BLVD STE 225
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-8178
Practice Address - Country:US
Practice Address - Phone:404-518-9414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009251101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty