Healthcare Provider Details

I. General information

NPI: 1487278982
Provider Name (Legal Business Name): EDWARD L LYELL MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9699 N FAIRY LILLY DR
CITRUS SPRINGS FL
34433-4052
US

IV. Provider business mailing address

7005 PROSPECT PL NE
ALBUQUERQUE NM
87110-4311
US

V. Phone/Fax

Practice location:
  • Phone: 505-730-6403
  • Fax:
Mailing address:
  • Phone: 104-200-6502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCCMH0171851
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH23167
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: