Provider Demographics
NPI:1124602354
Name:LYETH, GENEVIEVE AUTUMN-ROSE JUDITH
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:AUTUMN-ROSE JUDITH
Last Name:LYETH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S DOUGLAS RD STE 230
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4108
Mailing Address - Country:US
Mailing Address - Phone:844-854-1116
Mailing Address - Fax:305-846-9711
Practice Address - Street 1:400 SAINT LOUIS ST STE 1
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1979
Practice Address - Country:US
Practice Address - Phone:844-244-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician