Provider Demographics
NPI:1124285010
Name:LEE, ELAINE IDA (BCBA, LPC)
Entity type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:IDA
Last Name:LEE
Suffix:
Gender:F
Credentials:BCBA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S78W18425 LIONS PARK DR APT 1
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-8703
Mailing Address - Country:US
Mailing Address - Phone:815-590-7466
Mailing Address - Fax:
Practice Address - Street 1:S78W18425 LIONS PARK DR APT 1
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150-8703
Practice Address - Country:US
Practice Address - Phone:815-590-7466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67-140103K00000X
IL178.005691101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor