Provider Demographics
NPI:1841615556
Name:LYTLE, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:LYTLE
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 1:1020 SW MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-2129
Mailing Address - Country:US
Mailing Address - Phone:971-241-5881
Mailing Address - Fax:
Practice Address - Street 1:1020 SW MAPLE ST.
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338
Practice Address - Country:US
Practice Address - Phone:971-241-5881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health