Provider Demographics
NPI:1194100727
Name:LEE UNIVERSITY
Entity type:Organization
Organization Name:LEE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LUDIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, BCBA-D
Authorized Official - Phone:423-961-3785
Mailing Address - Street 1:1120 N OCOEE ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-4458
Mailing Address - Country:US
Mailing Address - Phone:423-614-8190
Mailing Address - Fax:423-614-9180
Practice Address - Street 1:1120 N OCOEE ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-4458
Practice Address - Country:US
Practice Address - Phone:423-614-8000
Practice Address - Fax:423-614-9180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-08-4396103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid