Provider Demographics
NPI:1588712327
Name:LEE, PRESLEY G (OT)
Entity type:Individual
Prefix:
First Name:PRESLEY
Middle Name:G
Last Name:LEE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 GASTON DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-9569
Mailing Address - Country:US
Mailing Address - Phone:662-843-2339
Mailing Address - Fax:662-846-1397
Practice Address - Street 1:16 GASTON DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-9569
Practice Address - Country:US
Practice Address - Phone:662-843-2339
Practice Address - Fax:662-846-1397
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1662225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07536763Medicaid