Provider Demographics
NPI:1083279160
Name:LYLE, MARY JANE (ISW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:LYLE
Suffix:
Gender:F
Credentials:ISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 LAKE MANGO WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-5182
Mailing Address - Country:US
Mailing Address - Phone:561-727-6169
Mailing Address - Fax:
Practice Address - Street 1:1439 LAKE MANGO WAY
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-5182
Practice Address - Country:US
Practice Address - Phone:561-727-6169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-05
Last Update Date:2019-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW132401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical