Provider Demographics
NPI:1306595665
Name:LEE, MAYLOGGS (LMT, MLD-C)
Entity type:Individual
Prefix:
First Name:MAYLOGGS
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:LMT, MLD-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:759 N MILWAUKEE ST STE 411
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3714
Mailing Address - Country:US
Mailing Address - Phone:414-376-7610
Mailing Address - Fax:
Practice Address - Street 1:759 N MILWAUKEE ST STE 411
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3714
Practice Address - Country:US
Practice Address - Phone:414-376-7610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15536-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist