Provider Demographics
NPI:1093034241
Name:LYTLE, KATHLEEN JOAN (LICSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JOAN
Last Name:LYTLE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 DUNLAP ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4619
Mailing Address - Country:US
Mailing Address - Phone:651-647-2116
Mailing Address - Fax:651-647-2201
Practice Address - Street 1:451 DUNLAP ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4619
Practice Address - Country:US
Practice Address - Phone:651-647-2116
Practice Address - Fax:651-647-2201
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical