1568481133 NPI number — MS. COLLEEN VIRGINIA LEE LMHC

Table of content: MS. COLLEEN VIRGINIA LEE LMHC (NPI 1568481133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568481133 NPI number — MS. COLLEEN VIRGINIA LEE LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
COLLEEN
Provider Middle Name:
VIRGINIA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIGDAHL
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
VIRGINIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1568481133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8257 NOOKSACK ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERSON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-885-6397
Provider Business Mailing Address Fax Number:
406-837-3363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
517 FRONT STREET, SUITE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNDEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-214-2062
Provider Business Practice Location Address Fax Number:
406-837-3363
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  60327290 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0256997 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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