Provider Demographics
NPI:1316764434
Name:FOURTE-LYLES, LATONYA (MA PSYCHOLOGY)
Entity type:Individual
Prefix:
First Name:LATONYA
Middle Name:
Last Name:FOURTE-LYLES
Suffix:
Gender:F
Credentials:MA PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3313 W 115TH ST
Mailing Address - Street 2:
Mailing Address - City:MERRIONETTE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60803-4556
Mailing Address - Country:US
Mailing Address - Phone:312-208-9511
Mailing Address - Fax:
Practice Address - Street 1:3313 W 115TH ST
Practice Address - Street 2:
Practice Address - City:MERRIONETTE PARK
Practice Address - State:IL
Practice Address - Zip Code:60803-4556
Practice Address - Country:US
Practice Address - Phone:312-208-9511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional