Provider Demographics
NPI:1003407602
Name:LYONS, JUSTIN (PTA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:LYONS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 HEWITT DR STE 107
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-8834
Mailing Address - Country:US
Mailing Address - Phone:254-572-8890
Mailing Address - Fax:
Practice Address - Street 1:1201 HEWITT DR STE 107
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8834
Practice Address - Country:US
Practice Address - Phone:254-572-8890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2158925225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant