Provider Demographics
NPI:1083697544
Name:SANDQUIST, LYLE J (PHD LMFT)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:J
Last Name:SANDQUIST
Suffix:
Gender:M
Credentials:PHD LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 MOUNTAIN DRIVE
Mailing Address - Street 2:STE 106
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2346
Mailing Address - Country:US
Mailing Address - Phone:850-837-9100
Mailing Address - Fax:850-837-7300
Practice Address - Street 1:215 MOUNTAIN DRIVE
Practice Address - Street 2:STE 106
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2346
Practice Address - Country:US
Practice Address - Phone:850-837-9100
Practice Address - Fax:850-837-7300
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT1053106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ1714OtherBCBS