Provider Demographics
NPI:1710108519
Name:LYON, EDWARD STEPHEN (CCS, CSAC, CCJP)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:STEPHEN
Last Name:LYON
Suffix:
Gender:M
Credentials:CCS, CSAC, CCJP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 BYRD ROAD
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:NC
Mailing Address - Zip Code:27576-9077
Mailing Address - Country:US
Mailing Address - Phone:910-301-9273
Mailing Address - Fax:910-738-1991
Practice Address - Street 1:4315 LUDGATE STREET
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2460
Practice Address - Country:US
Practice Address - Phone:910-301-9273
Practice Address - Fax:910-738-1991
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC263101YA0400X
NC#1429103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6110514Medicaid
NCCSAC #1429OtherNORTH CAROLINA SUBSTANCE ABUSE PROFESSIONAL PRACTICE BOARD
NCCCS # 263OtherNCSAPPB NORTH CAROLINA SUBSTANCE ABUSE PROFESSIONAL PRACTICE BOARD