Healthcare Provider Details

I. General information

NPI: 1427670348
Provider Name (Legal Business Name): MARIA LYTLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 SE DIVISION ST
PORTLAND OR
97202-1898
US

IV. Provider business mailing address

3050 SE DIVISION ST STE 215
PORTLAND OR
97202-1997
US

V. Phone/Fax

Practice location:
  • Phone: 503-622-8964
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: