Provider Demographics
NPI:1740933282
Name:LYLE, KATHRYN MARY (LGSW)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARY
Last Name:LYLE
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 RUDDER RD
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25443-4239
Mailing Address - Country:US
Mailing Address - Phone:843-957-1034
Mailing Address - Fax:
Practice Address - Street 1:179 E BURR BLVD STE L
Practice Address - Street 2:
Practice Address - City:KEARNEYSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25430-4964
Practice Address - Country:US
Practice Address - Phone:304-268-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSW112116078101YM0800X
WVBP009461591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health