Provider Demographics
NPI:1144310194
Name:LEE, BONNIE MAE (MSW)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:MAE
Last Name:LEE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-9116
Mailing Address - Country:US
Mailing Address - Phone:904-605-4986
Mailing Address - Fax:941-460-5599
Practice Address - Street 1:2270 HOLMGREN WAY
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-4710
Practice Address - Country:US
Practice Address - Phone:920-544-5294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3093-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI84238Medicaid
WI88076Medicare ID - Type Unspecified