Healthcare Provider Details

I. General information

NPI: 1093034241
Provider Name (Legal Business Name): KATHLEEN JOAN LYTLE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 05/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 DUNLAP ST N
SAINT PAUL MN
55104-4619
US

IV. Provider business mailing address

451 DUNLAP ST N
SAINT PAUL MN
55104-4619
US

V. Phone/Fax

Practice location:
  • Phone: 651-647-2116
  • Fax: 651-647-2201
Mailing address:
  • Phone: 651-647-2116
  • Fax: 651-647-2201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2622
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: