Provider Demographics
NPI:1235803511
Name:LYONS, DIANA MARIE (BCABA, LABA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:LYONS
Suffix:
Gender:F
Credentials:BCABA, LABA
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:MARIE
Other - Last Name:DICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1314 RIVERLAND RD SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-3610
Mailing Address - Country:US
Mailing Address - Phone:866-565-7222
Mailing Address - Fax:877-734-1914
Practice Address - Street 1:1314 RIVERLAND RD SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-3610
Practice Address - Country:US
Practice Address - Phone:866-565-7222
Practice Address - Fax:877-734-1914
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0134000368106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1235803511Medicaid