Provider Demographics
NPI:1972341329
Name:LEE, HEIDI JAEEUN
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:JAEEUN
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 1:4728 59TH PL APT 1
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-5619
Mailing Address - Country:US
Mailing Address - Phone:646-823-3940
Mailing Address - Fax:
Practice Address - Street 1:4728 59TH PL APT 1
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-5619
Practice Address - Country:US
Practice Address - Phone:646-823-3940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034453235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist