Healthcare Provider Details

I. General information

NPI: 1649813023
Provider Name (Legal Business Name): AMANDA LYTLE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 NORTHERN BLVD STE 304
ROSLYN NY
11576-1506
US

IV. Provider business mailing address

25 MILLFORD DR
LOCUST VALLEY NY
11560-1224
US

V. Phone/Fax

Practice location:
  • Phone: 516-331-1560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number023402
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: