Provider Demographics
NPI:1497716138
Name:LYON, ALISSA D (LCSW)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:D
Last Name:LYON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W. FORT ST.
Mailing Address - Street 2:VA MEDICAL CENTER (B116)
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4598
Mailing Address - Country:US
Mailing Address - Phone:208-422-1000
Mailing Address - Fax:208-422-1496
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:208-422-1496
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW256401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1693506Medicare ID - Type UnspecifiedCIGNA