Provider Demographics
NPI:1871731851
Name:LEE, MOZELLE MARSHALL (LISW)
Entity type:Individual
Prefix:
First Name:MOZELLE
Middle Name:MARSHALL
Last Name:LEE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1424
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29622-1424
Mailing Address - Country:US
Mailing Address - Phone:864-225-0792
Mailing Address - Fax:864-226-3968
Practice Address - Street 1:1115 DUNLAP RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2501
Practice Address - Country:US
Practice Address - Phone:864-225-0792
Practice Address - Fax:864-226-3968
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC45191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ325200281Medicare PIN