Provider Demographics
NPI:1962543801
Name:LYLES, MARY M (LCSW, PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:LYLES
Suffix:
Gender:F
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24044 CINCO VILLAGE CENTER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-8433
Mailing Address - Country:US
Mailing Address - Phone:832-576-2526
Mailing Address - Fax:281-886-0481
Practice Address - Street 1:24044 CINCO VILLAGE CENTER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-8433
Practice Address - Country:US
Practice Address - Phone:832-576-2526
Practice Address - Fax:281-886-0481
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9923451041C0700X
TX514041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical