Provider Demographics
NPI:1235683954
Name:LYONS, TIMOTHY (PSYD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:LYONS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2284
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-2284
Mailing Address - Country:US
Mailing Address - Phone:209-418-4822
Mailing Address - Fax:
Practice Address - Street 1:3749 SUDBURY RD
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8613
Practice Address - Country:US
Practice Address - Phone:209-418-4822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 390200000X
CA34809103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1235683954Medicaid