Provider Demographics
NPI:1194254821
Name:LYLES, FONDA ALTHEA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:FONDA
Middle Name:ALTHEA
Last Name:LYLES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 BRUCE FARM DR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1255
Mailing Address - Country:US
Mailing Address - Phone:757-537-2919
Mailing Address - Fax:
Practice Address - Street 1:4400 BRUCE FARM DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-1255
Practice Address - Country:US
Practice Address - Phone:757-537-2919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040088851041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical