Provider Demographics
NPI:1063564516
Name:LEE, JOHN (LICSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3085 BROAD ST
Mailing Address - Street 2:SUITE I
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37408-3084
Mailing Address - Country:US
Mailing Address - Phone:423-248-2482
Mailing Address - Fax:888-420-3050
Practice Address - Street 1:3085 BROAD ST
Practice Address - Street 2:SUITE I
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37408-3084
Practice Address - Country:US
Practice Address - Phone:423-248-2482
Practice Address - Fax:888-420-3050
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2012-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1133741041C0700X
2118861041C0700X
TN55751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical