Basic Information
| Provider Information | |||||||||
| NPI: | 1326395534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYLES | ||||||||
| FirstName: | AISHA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | AISHA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 180 JACKSON ST NE APT 2318 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303121370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785160639 | ||||||||
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| Practice Location | |||||||||
| Address1: | 64 DANBURY RD | ||||||||
| Address2: | |||||||||
| City: | WILTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068974429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002780332 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2012 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT005489 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | OT005489 | 01 | GA | GEORGIA BOARD OF OCCUPATIONAL THERAPY | OTHER |