Provider Demographics
NPI:1114571395
Name:LYONS, WAYNE II
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:LYONS
Suffix:II
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 1:18272 W 12 MILE RD APT 310
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2668
Mailing Address - Country:US
Mailing Address - Phone:313-247-7979
Mailing Address - Fax:
Practice Address - Street 1:41521 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1803
Practice Address - Country:US
Practice Address - Phone:248-436-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801103373104100000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician