Provider Demographics
NPI:1699308007
Name:LEE, ELIZABETH WILCOSKY
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:WILCOSKY
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 1:296 SUMMER ST # 1
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-3114
Mailing Address - Country:US
Mailing Address - Phone:919-636-0351
Mailing Address - Fax:
Practice Address - Street 1:12 TYLER ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-3241
Practice Address - Country:US
Practice Address - Phone:617-629-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist