Healthcare Provider Details

I. General information

NPI: 1417304791
Provider Name (Legal Business Name): KIM JEANNETTE LYTLE MS LPC CAADC NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N MAIN ST SUITE 202
CHEBOYGAN MI
49721-1162
US

IV. Provider business mailing address

520 N MAIN ST SUITE 202
CHEBOYGAN MI
49721-1162
US

V. Phone/Fax

Practice location:
  • Phone: 231-597-9235
  • Fax: 231-627-4201
Mailing address:
  • Phone: 231-597-9235
  • Fax: 231-627-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401014824
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: