Basic Information
| Provider Information | |||||||||
| NPI: | 1255981676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JOEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6211 NOTTAWAY DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711196216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185108991 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9403 MANSFIELD RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711183815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188618938 | ||||||||
| FaxNumber: | 3188623554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2019 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | LA | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1760852511 | 01 | LA | PELICAN BAYOU COUNSELING AGENCY | OTHER |