Provider Demographics
NPI:1235941493
Name:LEE, KYSHAU CORIN
Entity type:Individual
Prefix:
First Name:KYSHAU
Middle Name:CORIN
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4470 MANNING RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228-6711
Mailing Address - Country:US
Mailing Address - Phone:317-701-7810
Mailing Address - Fax:
Practice Address - Street 1:7208 DOBSON ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-2128
Practice Address - Country:US
Practice Address - Phone:317-654-6806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-22-227781106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician