Provider Demographics
NPI:1194060269
Name:LEE, PETER D (LICSW)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:D
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 1:1 RICHMOND SQ
Mailing Address - Street 2:SUITE 109-C
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 RICHMOND SQ
Practice Address - Street 2:SUITE 109-C
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5139
Practice Address - Country:US
Practice Address - Phone:401-451-6474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW000031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical