Provider Demographics
NPI:1124500285
Name:LYONS, MONTGOMERY
Entity type:Individual
Prefix:
First Name:MONTGOMERY
Middle Name:
Last Name:LYONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MA
Mailing Address - Zip Code:01541-1108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:162 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MA
Practice Address - Zip Code:01541-1108
Practice Address - Country:US
Practice Address - Phone:844-222-6037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY023685103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program