Provider Demographics
NPI:1740614999
Name:LYLES, CHARLENE S
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:S
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 1:2981 CRAVENRIDGE DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-2923
Mailing Address - Country:US
Mailing Address - Phone:678-591-7480
Mailing Address - Fax:
Practice Address - Street 1:6600 PEACHTREE DUNWOODY RD
Practice Address - Street 2:BUILDING 400, SUITE 125
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-6773
Practice Address - Country:US
Practice Address - Phone:678-587-9922
Practice Address - Fax:866-587-9993
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002930225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist