Provider Demographics
NPI:1053777995
Name:LEE, TANDRA NICOLE BROWN (LICSW, LCSW-C)
Entity type:Individual
Prefix:
First Name:TANDRA
Middle Name:NICOLE BROWN
Last Name:LEE
Suffix:
Gender:F
Credentials:LICSW, LCSW-C
Other - Prefix:
Other - First Name:TANDRA
Other - Middle Name:NICOLE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LGSW
Mailing Address - Street 1:3519 REGENCY PKWY
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-3819
Mailing Address - Country:US
Mailing Address - Phone:240-274-4702
Mailing Address - Fax:
Practice Address - Street 1:3519 REGENCY PKWY
Practice Address - Street 2:
Practice Address - City:DISTRICT HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20747-3819
Practice Address - Country:US
Practice Address - Phone:240-274-4702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD139151041C0700X
DCLC500812391041C0700X
DCLG50079107104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD13915OtherLCSW-C
LG50079107OtherDISTRICT OF COLUMBIA BOARD OF SOCIAL WORK
DCLC50081239OtherLICSW