Provider Demographics
NPI:1962981431
Name:LYONS, HAZEL JOSA MAE (CDCA)
Entity type:Individual
Prefix:MRS
First Name:HAZEL
Middle Name:JOSA MAE
Last Name:LYONS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22664 STATE ROUTE 73
Mailing Address - Street 2:
Mailing Address - City:WEST PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45663-6365
Mailing Address - Country:US
Mailing Address - Phone:740-858-6690
Mailing Address - Fax:740-858-6693
Practice Address - Street 1:22664 STATE ROUTE 73
Practice Address - Street 2:
Practice Address - City:WEST PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45663-6365
Practice Address - Country:US
Practice Address - Phone:740-858-6690
Practice Address - Fax:740-858-6693
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH166897101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1548782816Medicaid