Provider Demographics
NPI:1093903478
Name:LYLES, ALISSA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:LYLES
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 N COLE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8638
Mailing Address - Country:US
Mailing Address - Phone:208-323-8888
Mailing Address - Fax:208-323-8889
Practice Address - Street 1:890 N COLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8638
Practice Address - Country:US
Practice Address - Phone:208-323-8888
Practice Address - Fax:208-323-8889
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1665235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist