Basic Information
| Provider Information | |||||||||
| NPI: | 1679666135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MS/LPE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1622 DONAGHEY AVE | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720343221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013277706 | ||||||||
| FaxNumber: | 5013282244 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728013362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799675570 | ||||||||
| FaxNumber: | 4798905364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 5Y591 | 01 | AR | ARK BCBS | OTHER |