Provider Demographics
NPI:1760824890
Name:MARR LYON, LISA RENEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:RENEE
Last Name:MARR LYON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3917 WEST ROAD, SUITE 128
Mailing Address - Street 2:LOS ALAMOS CHILDREN'S CLINIC
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544
Mailing Address - Country:US
Mailing Address - Phone:505-662-4234
Mailing Address - Fax:
Practice Address - Street 1:3917 WEST ROAD, SUITE 128
Practice Address - Street 2:CHILDREN'S CLINIC, P.A.
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:US
Practice Address - Phone:505-662-4234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM306556103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool