MEDICARE: LINDA RISSER LYTLE PH.D.

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	103TC0700X	Clinical Psychologist	1533	DC

General Provider Information

NPI Number	:	1710040464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINDA RISSER LYTLE PH.D.

Provider Business Mailing Address
First Line	:	4300 TUCKERMAN ST
Second Line	:
City	:	UNIVERSITY PARK
State	:	MD
Zip	:	20782-2145
Country	:	US
Telephone Number	:	301-779-0456
Fax Number	:	301-779-0456

Provider Business Practice Location Address
First Line	:	1609 CONNECTICUT AVE NW
Second Line	:	SUITE 300
City	:	WASHINGTON
State	:	DC
Zip	:	20009-1034
Country	:	US
Telephone Number	:	301-779-0456
Fax Number	:	301-779-0456

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

Provider Enumeration Date	:	12/17/2006
Last Update Date	:	07/08/2007

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