Basic Information
| Provider Information | |||||||||
| NPI: | 1568982999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYON | ||||||||
| FirstName: | JOHNATHAN | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 97 | ||||||||
| Address2: | |||||||||
| City: | BAKER | ||||||||
| State: | WV | ||||||||
| PostalCode: | 268010097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048975915 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 S GROVE ST | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 268471770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042572451 | ||||||||
| FaxNumber: | 3042571263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2017 | ||||||||
| LastUpdateDate: | 06/27/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | BP00945109 | WV | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.