Provider Demographics
NPI:1699025866
Name:LYLE, EBONEE MONIQUE (LCSW)
Entity type:Individual
Prefix:MS
First Name:EBONEE
Middle Name:MONIQUE
Last Name:LYLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8134
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-286-1700
Mailing Address - Fax:314-286-1730
Practice Address - Street 1:4444 FOREST PARK AVE
Practice Address - Street 2:STE 2600
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2212
Practice Address - Country:US
Practice Address - Phone:314-286-1700
Practice Address - Fax:314-286-1777
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100358261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499417301Medicaid