Basic Information
| Provider Information | |||||||||
| NPI: | 1063521326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 W THOMAS RD # 301 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063671 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 222 W THOMAS RD STE 315 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063671 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 001130 | GA | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | 1130 | GA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103G00000X | 4848 | AZ | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 000338434A | 05 | GA | MEDICAID | PS0182 | 01 | SC | SC MEDICAID | OTHER |