Provider Demographics
NPI:1518554245
Name:LYLES, KELSEY DIONNA
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:DIONNA
Last Name:LYLES
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 1:634 N MAIN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3746
Mailing Address - Country:US
Mailing Address - Phone:618-726-5870
Mailing Address - Fax:
Practice Address - Street 1:634 N MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3746
Practice Address - Country:US
Practice Address - Phone:618-726-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILL420-5040-0747106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician