Provider Demographics
NPI:1871876839
Name:LEE, MARY LOU E (OTR)
Entity type:Individual
Prefix:
First Name:MARY LOU
Middle Name:E
Last Name:LEE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 JORDAN BLVD
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-4105
Mailing Address - Country:US
Mailing Address - Phone:518-729-5159
Mailing Address - Fax:
Practice Address - Street 1:2072 CURRY RD
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12303-4400
Practice Address - Country:US
Practice Address - Phone:518-356-8221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002423-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist