MEDICARE: MARY JANE LYLE ISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	ISW13240	FL

General Provider Information

NPI Number	:	1083279160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JANE LYLE ISW

Provider Business Mailing Address
First Line	:	1439 LAKE MANGO WAY
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-5182
Country	:	US
Telephone Number	:	561-727-6169
Fax Number	:

Provider Business Practice Location Address
First Line	:	1439 LAKE MANGO WAY
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-5182
Country	:	US
Telephone Number	:	561-727-6169
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2019
Last Update Date	:	05/05/2019

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