Healthcare Provider Details

I. General information

NPI: 1104416841
Provider Name (Legal Business Name): MANCELL VONTRELL LYTTLE CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 S SOUTH ST
WILMINGTON OH
45177-2755
US

IV. Provider business mailing address

4120 BROOKDALE LN UNIT 5
DAYTON OH
45440-3998
US

V. Phone/Fax

Practice location:
  • Phone: 937-910-6218
  • Fax: 800-480-7578
Mailing address:
  • Phone: 313-687-9586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.193768
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: