Provider Demographics
NPI:1518359868
Name:LYONS, MANDA LOUISE CARMEN (BSW)
Entity Type:Individual
Prefix:
First Name:MANDA
Middle Name:LOUISE CARMEN
Last Name:LYONS
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:MANDA
Other - Middle Name:LOUISE CARMEN
Other - Last Name:HATCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW
Mailing Address - Street 1:55 NE GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2968
Mailing Address - Country:US
Mailing Address - Phone:971-230-7563
Mailing Address - Fax:
Practice Address - Street 1:6430 SE 66TH AVE
Practice Address - Street 2:A
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-6620
Practice Address - Country:US
Practice Address - Phone:503-309-9089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health