Healthcare Provider Details

I. General information

NPI: 1558075168
Provider Name (Legal Business Name): MELISSA LOUISE LYLES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 HIGHWAY 80 W STE R
CLINTON MS
39056-4108
US

IV. Provider business mailing address

572 TURTLE LN
BRANDON MS
39047-5087
US

V. Phone/Fax

Practice location:
  • Phone: 601-473-2106
  • Fax:
Mailing address:
  • Phone: 601-212-9744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC10350
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: