Provider Demographics
NPI:1104416841
Name:LYTTLE, MANCELL VONTRELL (CDCA)
Entity type:Individual
Prefix:MR
First Name:MANCELL
Middle Name:VONTRELL
Last Name:LYTTLE
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 BROOKDALE LN UNIT 5
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-3998
Mailing Address - Country:US
Mailing Address - Phone:313-687-9586
Mailing Address - Fax:
Practice Address - Street 1:815 S SOUTH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2755
Practice Address - Country:US
Practice Address - Phone:937-910-6218
Practice Address - Fax:800-480-7578
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.193768101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid