Provider Demographics
NPI:1063521326
Name:LEE, GREGORY P (PHD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:P
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 1:240 W THOMAS RD # 301
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4407
Mailing Address - Country:US
Mailing Address - Phone:602-406-3671
Mailing Address - Fax:
Practice Address - Street 1:222 W THOMAS RD STE 315
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013
Practice Address - Country:US
Practice Address - Phone:602-406-3671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001130103G00000X
GA1130103TC0700X
AZ4848103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000338434AMedicaid
SCPS0182OtherSC MEDICAID
GA68BBFRLMedicare PIN
SCPS0182Medicaid