Healthcare Provider Details

I. General information

NPI: 1518974872
Provider Name (Legal Business Name): EDWARD LYTLE BCSAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 RAINBOW DR UNIT 35
PINEVILLE LA
71360-6979
US

IV. Provider business mailing address

303 HOLIDAY CIR
PINEVILLE LA
71360-5531
US

V. Phone/Fax

Practice location:
  • Phone: 318-487-5190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number988
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: