Provider Demographics
NPI:1730528373
Name:LEE, SU JIN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SU JIN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 NEW SOUTH DR APT 1207
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8429
Mailing Address - Country:US
Mailing Address - Phone:813-435-8328
Mailing Address - Fax:
Practice Address - Street 1:298 CLEAR SKY CT STE G
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5685
Practice Address - Country:US
Practice Address - Phone:931-542-2739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17738235Z00000X
TN4980235Z00000X
KY4230235Z00000X
ND1229235Z00000X
MN8971235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
201086967OtherUSCIS NUMBER