Provider Demographics
NPI:1679875520
Name:MARK LYTLE ASSOCIATES A PSYCHOLOGY CORPORATION
Entity Type:Organization
Organization Name:MARK LYTLE ASSOCIATES A PSYCHOLOGY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:LYTLE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:858-566-4748
Mailing Address - Street 1:11280 TRIBUNA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1929
Mailing Address - Country:US
Mailing Address - Phone:858-566-4748
Mailing Address - Fax:858-566-4748
Practice Address - Street 1:3636 4TH AVE
Practice Address - Street 2:#302
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4280
Practice Address - Country:US
Practice Address - Phone:858-566-4748
Practice Address - Fax:858-566-4748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12089103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY120892Medicaid
CACP12089Medicare PIN