Provider Demographics
NPI:1265655427
Name:LYLES, ED DAVIS (LCSW)
Entity Type:Individual
Prefix:
First Name:ED
Middle Name:DAVIS
Last Name:LYLES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 CITY VIEW DR
Mailing Address - Street 2:#302
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5327
Mailing Address - Country:US
Mailing Address - Phone:307-789-7915
Mailing Address - Fax:307-789-6009
Practice Address - Street 1:350 CITY VIEW DR
Practice Address - Street 2:#302
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5327
Practice Address - Country:US
Practice Address - Phone:307-789-7915
Practice Address - Fax:307-789-6009
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-4081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY313191OtherBCBS OF WYOMING
WY313191OtherBCBS OF WYOMING