Basic Information
| Provider Information | |||||||||
| NPI: | 1114454279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | KIANDRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3625 YOUREE DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711052121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187423408 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 908 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712015844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183258748 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.