Provider Demographics
NPI:1639790264
Name:LYONS, LATASHA NICOLE
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:NICOLE
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 1:1004 MULLIGAN DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2099
Mailing Address - Country:US
Mailing Address - Phone:708-238-1876
Mailing Address - Fax:
Practice Address - Street 1:1004 MULLIGAN DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2099
Practice Address - Country:US
Practice Address - Phone:708-238-1876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015569101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional