Provider Demographics
NPI:1184932766
Name:LYLE, JOHN A (MA, LLP)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:LYLE
Suffix:
Gender:M
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12868 GABLE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48212-2528
Mailing Address - Country:US
Mailing Address - Phone:313-875-5183
Mailing Address - Fax:313-875-9160
Practice Address - Street 1:3501 HAMTRAMCK DR
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48211-1400
Practice Address - Country:US
Practice Address - Phone:313-875-5183
Practice Address - Fax:313-875-9160
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009578103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist