Provider Demographics
NPI:1801316294
Name:LYLES, KIMBERLY (MSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LYLES
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 WHITE ST
Mailing Address - Street 2:PO BOX 768
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648
Mailing Address - Country:US
Mailing Address - Phone:601-249-4214
Mailing Address - Fax:601-249-4234
Practice Address - Street 1:1701 WHITE ST
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648
Practice Address - Country:US
Practice Address - Phone:601-249-4214
Practice Address - Fax:601-249-4234
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X, 171M00000X
LA13504104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA640897031Medicaid