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NPI Code Detail

MEDICARE: MR. MANCELL VONTRELL LYTTLE CDCA

MEDICARE: MR. MANCELL VONTRELL LYTTLE CDCA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) CounselorCDCA.193768OH

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1104416841
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MANCELL VONTRELL LYTTLE CDCA
Provider Business Mailing Address
First Line : 4120 BROOKDALE LN UNIT 5
Second Line :
City : DAYTON
State : OH
Zip : 45440-3998
Country : US
Telephone Number : 313-687-9586
Fax Number :
Provider Business Practice Location Address
First Line : 815 S SOUTH ST
Second Line :
City : WILMINGTON
State : OH
Zip : 45177-2755
Country : US
Telephone Number : 937-910-6218
Fax Number : 800-480-7578
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/26/2021
Last Update Date : 09/29/2025

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