Healthcare Provider Details

I. General information

NPI: 1174010649
Provider Name (Legal Business Name): JODI ANNE LYTLE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 E MAIN ST STE A
CENTREVILLE MI
49032-8525
US

IV. Provider business mailing address

677 E MAIN ST STE A
CENTREVILLE MI
49032-8525
US

V. Phone/Fax

Practice location:
  • Phone: 269-467-1000
  • Fax: 269-467-3072
Mailing address:
  • Phone: 269-467-1000
  • Fax: 269-467-3072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801090511
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: