Provider Demographics
NPI:1760273288
Name:LEE, PHYLICIA K (LMSW)
Entity type:Individual
Prefix:
First Name:PHYLICIA
Middle Name:K
Last Name:LEE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-3135
Mailing Address - Country:US
Mailing Address - Phone:208-604-6877
Mailing Address - Fax:
Practice Address - Street 1:725 JENSEN GROVE DR STE 4
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1636
Practice Address - Country:US
Practice Address - Phone:208-604-6877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker