Provider Demographics
NPI:1912664731
Name:LYLES, BRENDAN
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:LYLES
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 1:1016 POPPY FIELDS LN
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-1844
Mailing Address - Country:US
Mailing Address - Phone:919-605-7923
Mailing Address - Fax:
Practice Address - Street 1:4070 BARRETT DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6604
Practice Address - Country:US
Practice Address - Phone:919-213-0134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16941101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty