Provider Demographics
NPI:1033781109
Name:LYONS, MITZIE MAY (MA MS LBC)
Entity Type:Individual
Prefix:
First Name:MITZIE
Middle Name:MAY
Last Name:LYONS
Suffix:
Gender:F
Credentials:MA MS LBC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 SPRUCE ST STE 295
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4115
Mailing Address - Country:US
Mailing Address - Phone:215-939-7005
Mailing Address - Fax:
Practice Address - Street 1:222 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:PA
Practice Address - Zip Code:19050-1609
Practice Address - Country:US
Practice Address - Phone:215-939-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH000312101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty