Provider Demographics
NPI:1730391467
Name:SKINNER, LYLE (PSYD, LCP)
Entity type:Individual
Prefix:DR
First Name:LYLE
Middle Name:
Last Name:SKINNER
Suffix:
Gender:M
Credentials:PSYD, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2713
Mailing Address - Country:US
Mailing Address - Phone:630-232-2458
Mailing Address - Fax:
Practice Address - Street 1:227 S 2ND ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2713
Practice Address - Country:US
Practice Address - Phone:630-232-2458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007295103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004532166OtherBCBSIL
364448546OtherEIN