Provider Demographics
NPI:1467859884
Name:LEE, DESTINY
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5681 SPRINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230-8330
Mailing Address - Country:US
Mailing Address - Phone:419-231-7709
Mailing Address - Fax:
Practice Address - Street 1:621 MOUNT VERNON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-4615
Practice Address - Country:US
Practice Address - Phone:740-670-7078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21033078103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool