Provider Demographics
NPI:1366065054
Name:LEE, MICHAEL (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 SUMTER WAY
Mailing Address - Street 2:
Mailing Address - City:PELL CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35128-7738
Mailing Address - Country:US
Mailing Address - Phone:210-818-6160
Mailing Address - Fax:
Practice Address - Street 1:60 SUMTER WAY
Practice Address - Street 2:
Practice Address - City:PELL CITY
Practice Address - State:AL
Practice Address - Zip Code:35128-7738
Practice Address - Country:US
Practice Address - Phone:210-818-6160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.016452101Y00000X
103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37-1303427003Medicaid
IL37-1303427005Medicaid