Provider Demographics
NPI:1013030048
Name:LYLES LYNN, JOSEPHINE M (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JOSEPHINE
Middle Name:M
Last Name:LYLES LYNN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305
Mailing Address - Country:US
Mailing Address - Phone:708-606-0984
Mailing Address - Fax:
Practice Address - Street 1:1024 N BOULEVARD
Practice Address - Street 2:SUITE 211
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301
Practice Address - Country:US
Practice Address - Phone:708-606-0984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01634783OtherBLUE CROSS BLUE SHIELD