Provider Demographics
NPI:1992742068
Name:LEE, FANIA (PSYD HSPP)
Entity type:Individual
Prefix:DR
First Name:FANIA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PSYD HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1317
Mailing Address - Country:US
Mailing Address - Phone:812-455-6597
Mailing Address - Fax:812-909-3245
Practice Address - Street 1:43 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1317
Practice Address - Country:US
Practice Address - Phone:812-455-6597
Practice Address - Fax:812-909-3245
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042013A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1992742068OtherNPI