Provider Demographics
NPI:1962880112
Name:CARLYLE, WILLETTE P (MA, LPC-MHSP)
Entity type:Individual
Prefix:MRS
First Name:WILLETTE
Middle Name:P
Last Name:CARLYLE
Suffix:
Gender:F
Credentials:MA, LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 MCCLAIN DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5552
Mailing Address - Country:US
Mailing Address - Phone:931-217-0947
Mailing Address - Fax:931-451-1347
Practice Address - Street 1:279 CLEAR SKY CT STE D
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5946
Practice Address - Country:US
Practice Address - Phone:931-237-4341
Practice Address - Fax:931-451-1347
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3352101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ032951Medicaid