Basic Information
| Provider Information | |||||||||
| NPI: | 1952648271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYON | ||||||||
| FirstName: | MCCALL | ||||||||
| MiddleName: | BOWCUT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOWCUT | ||||||||
| OtherFirstName: | MCCALL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 350 S 400 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841112908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015825534 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5242 S 4820 W | ||||||||
| Address2: | |||||||||
| City: | KEARNS | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841186422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019664251 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2013 | ||||||||
| LastUpdateDate: | 10/13/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 9533115-2501 | UT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.