Provider Demographics
NPI:1558068874
Name:LYONS, TAWANA D
Entity Type:Individual
Prefix:
First Name:TAWANA
Middle Name:D
Last Name:LYONS
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 1:2332 GILSON ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-3010
Mailing Address - Country:US
Mailing Address - Phone:262-287-6222
Mailing Address - Fax:
Practice Address - Street 1:2332 GILSON ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-3010
Practice Address - Country:US
Practice Address - Phone:262-800-1032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0018876320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPROV0002293446OtherDHS
WI0002293446OtherIRS