Healthcare Provider Details

I. General information

NPI: 1598007650
Provider Name (Legal Business Name): SHIRLEY E LYTLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 112TH AVE NE #302
BELLEVUE WA
98004-5800
US

IV. Provider business mailing address

22902 43RD DR SE
BOTHELL WA
98021-9117
US

V. Phone/Fax

Practice location:
  • Phone: 425-998-7123
  • Fax:
Mailing address:
  • Phone: 425-998-7123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60202037
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: