Provider Demographics
NPI:1285037267
Name:LYON, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LYON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4623 FALLS RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4914
Mailing Address - Country:US
Mailing Address - Phone:410-366-1980
Mailing Address - Fax:410-366-8530
Practice Address - Street 1:815 RITCHIE HWY
Practice Address - Street 2:SUITE 126
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-4118
Practice Address - Country:US
Practice Address - Phone:410-571-8341
Practice Address - Fax:410-571-8368
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC5968101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4231627 00Medicaid