Healthcare Provider Details

I. General information

NPI: 1710040464
Provider Name (Legal Business Name): LINDA RISSER LYTLE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 CONNECTICUT AVE NW SUITE 300
WASHINGTON DC
20009-1034
US

IV. Provider business mailing address

4300 TUCKERMAN ST
UNIVERSITY PARK MD
20782-2145
US

V. Phone/Fax

Practice location:
  • Phone: 301-779-0456
  • Fax: 301-779-0456
Mailing address:
  • Phone: 301-779-0456
  • Fax: 301-779-0456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1533
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: