Provider Demographics
NPI:1811662604
Name:LYTLE, ADELLE
Entity type:Individual
Prefix:
First Name:ADELLE
Middle Name:
Last Name:LYTLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 REDDY FARM LN
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1758
Mailing Address - Country:US
Mailing Address - Phone:678-863-9354
Mailing Address - Fax:
Practice Address - Street 1:2122 REDDY FARM LN
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-1758
Practice Address - Country:US
Practice Address - Phone:678-464-3229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health