Provider Demographics
NPI:1083460190
Name:LEE, GARY P (LCAS-A)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:P
Last Name:LEE
Suffix:
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:P
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCAS-A
Mailing Address - Street 1:2402 CAMDEN ST SW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-8608
Mailing Address - Country:US
Mailing Address - Phone:252-367-9081
Mailing Address - Fax:
Practice Address - Street 1:2253 BIRCH HOLLOW DR
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-1137
Practice Address - Country:US
Practice Address - Phone:252-367-9081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-29798101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)