Provider Demographics
NPI:1124558614
Name:LYONS, KENNETH ROBERT (MS, SUDP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
Last Name:LYONS
Suffix:
Gender:M
Credentials:MS, SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3639 MLK JR WAY SOUTH
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3639 MLK JR WAY S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144
Practice Address - Country:US
Practice Address - Phone:206-805-8972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61249696101YA0400X
WACO60906258101Y00000X
WACG60475258101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2110425Medicaid