1265655427 NPI number — ED DAVIS LYLES LCSW

Table of content: ED DAVIS LYLES LCSW (NPI 1265655427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265655427 NPI number — ED DAVIS LYLES LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYLES
Provider First Name:
ED
Provider Middle Name:
DAVIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265655427
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 CITY VIEW DR
Provider Second Line Business Mailing Address:
#302
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82930-5327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-789-7915
Provider Business Mailing Address Fax Number:
307-789-6009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 CITY VIEW DR
Provider Second Line Business Practice Location Address:
#302
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82930-5327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-789-7915
Provider Business Practice Location Address Fax Number:
307-789-6009
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCSW-408 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 313191 . This is a "BCBS OF WYOMING" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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