Basic Information
| Provider Information | |||||||||
| NPI: | 1629579438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYONS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2685 ARMSTRONG RD | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446919041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303457949 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2685 ARMSTRONG RD | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446919041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303457949 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2018 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 104100000X | S.2208115 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.