Healthcare Provider Details

I. General information

NPI: 1063877132
Provider Name (Legal Business Name): BRIAN LYTTLE I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9514 CONEY ISLAND CIR
ELK GROVE CA
95758-3646
US

IV. Provider business mailing address

9514 CONEY ISLAND CIR
ELK GROVE CA
95758-3646
US

V. Phone/Fax

Practice location:
  • Phone: 916-206-9242
  • Fax:
Mailing address:
  • Phone: 916-206-9242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: