Provider Demographics
NPI:1821240078
Name:LYON, MARY ELLEN (CCC-SLP, AUD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:LYON
Suffix:
Gender:F
Credentials:CCC-SLP, AUD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:POTTORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUDIOLOGIST
Mailing Address - Street 1:8700 E 29TH ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-2169
Mailing Address - Country:US
Mailing Address - Phone:316-634-8710
Mailing Address - Fax:316-634-8850
Practice Address - Street 1:8700 E 29TH ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2169
Practice Address - Country:US
Practice Address - Phone:316-634-8710
Practice Address - Fax:316-634-8850
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS801231H00000X
231H00000X
KS3043235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist