Basic Information
| Provider Information | |||||||||
| NPI: | 1992863484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | DWYER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DWYER | ||||||||
| OtherFirstName: | MARGARET | ||||||||
| OtherMiddleName: | MARY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1406 6TH AVENUE NORTH | ||||||||
| Address2: | ST CLOUD HOSPITAL | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3206567115 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 6TH AVENUE NORTH | ||||||||
| Address2: | ST CLOUD HOSPITAL | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3206567115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 10/31/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP3586 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | LP3586 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1013101 | 01 | PREFERRED ONE | OTHER | 6143788 | 01 | UBH | OTHER | 6H677DW | 01 | BLUE CROSS | OTHER | 116131 | 01 | UCARE | OTHER | 561724300 | 05 | MN | MEDICAID |