Provider Demographics
NPI:1326395534
Name:LYLES, AISHA
Entity Type:Individual
Prefix:
First Name:AISHA
Middle Name:
Last Name:LYLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AISHA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:180 JACKSON ST NE APT 2318
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1370
Mailing Address - Country:US
Mailing Address - Phone:678-516-0639
Mailing Address - Fax:
Practice Address - Street 1:64 DANBURY RD
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-4429
Practice Address - Country:US
Practice Address - Phone:800-278-0332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005489225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT005489OtherGEORGIA BOARD OF OCCUPATIONAL THERAPY