=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275637696
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYLE NORBERT NEEB LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119A S. SILVER LAKE ST
-----------------------------------------------------
City | OCONOMOWOC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-567-4455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N48W34100 JAECKLES DR
-----------------------------------------------------
City | NASHOTAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53058-9631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-567-7713
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 4292-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------