Provider Demographics
NPI:1427281559
Name:SPAIN, LEE SHALAMAR (DO)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:SHALAMAR
Last Name:SPAIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-373-5266
Mailing Address - Fax:814-373-5269
Practice Address - Street 1:640 ALDEN ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335
Practice Address - Country:US
Practice Address - Phone:814-373-5266
Practice Address - Fax:814-373-5269
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT0133172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOS016003OtherLICENSE
PA101268168Medicaid