Provider Demographics
NPI:1568481133
Name:LEE, COLLEEN VIRGINIA (LMHC)
Entity type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:VIRGINIA
Last Name:LEE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:VIRGINIA
Other - Last Name:WIGDAHL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8257 NOOKSACK ROAD
Mailing Address - Street 2:
Mailing Address - City:EVERSON
Mailing Address - State:WA
Mailing Address - Zip Code:98247
Mailing Address - Country:US
Mailing Address - Phone:406-885-6397
Mailing Address - Fax:406-837-3363
Practice Address - Street 1:517 FRONT STREET, SUITE D
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264
Practice Address - Country:US
Practice Address - Phone:360-214-2062
Practice Address - Fax:406-837-3363
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60327290101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0256997Medicaid