Provider Demographics
NPI:1215202379
Name:LEE, KATHLEEN MARY (COTA)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARY
Last Name:LEE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 483
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12602-0483
Mailing Address - Country:US
Mailing Address - Phone:845-204-4626
Mailing Address - Fax:
Practice Address - Street 1:156 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MARLBORO
Practice Address - State:NY
Practice Address - Zip Code:12542-6304
Practice Address - Country:US
Practice Address - Phone:845-204-4626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007043174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY007043OtherNEW YORK STATE LICENSE NUMBER