Provider Demographics
NPI:1194122317
Name:LEE, SHAWN A
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:A
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17889 N WHEELING AVE
Mailing Address - Street 2:
Mailing Address - City:GASTON
Mailing Address - State:IN
Mailing Address - Zip Code:47342-8923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 S WASHINGTON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-3867
Practice Address - Country:US
Practice Address - Phone:765-662-9971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006428A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100124250Medicaid