Provider Demographics
NPI:1164175121
Name:FRIED, LYLE R (CAP, ICADC)
Entity Type:Individual
Prefix:MR
First Name:LYLE
Middle Name:R
Last Name:FRIED
Suffix:
Gender:M
Credentials:CAP, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5785 NW WESLEY RD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-4207
Mailing Address - Country:US
Mailing Address - Phone:772-332-8711
Mailing Address - Fax:
Practice Address - Street 1:5785 NW WESLEY RD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-4207
Practice Address - Country:US
Practice Address - Phone:772-332-8711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4805101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty