Provider Demographics
NPI:1366894487
Name:LEE, BAO
Entity type:Individual
Prefix:
First Name:BAO
Middle Name:
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 1:25 KESSEL CT STE 105
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6227
Mailing Address - Country:US
Mailing Address - Phone:608-280-2636
Mailing Address - Fax:
Practice Address - Street 1:3518 MEMORIAL DR
Practice Address - Street 2:BLDG 4
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-1574
Practice Address - Country:US
Practice Address - Phone:608-280-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3125-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health