Provider Demographics
NPI:1639458102
Name:DAVIS, LYLE (LCSW)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:
Last Name:DAVIS
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 1:1524 ARGYLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1542
Mailing Address - Country:US
Mailing Address - Phone:954-298-8949
Mailing Address - Fax:
Practice Address - Street 1:1620 W OAKLAND PARK BLVD STE 403
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33311-1533
Practice Address - Country:US
Practice Address - Phone:954-298-8949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 104531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical