Provider Demographics
NPI:1669172763
Name:LYTCH, IMANI
Entity type:Individual
Prefix:
First Name:IMANI
Middle Name:
Last Name:LYTCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16601 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-2714
Mailing Address - Country:US
Mailing Address - Phone:725-277-5433
Mailing Address - Fax:
Practice Address - Street 1:14804 N CAVE CREEK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4945
Practice Address - Country:US
Practice Address - Phone:980-230-1759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician