Provider Demographics
NPI:1922055474
Name:LYONS, SEAN P (OTRL)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:P
Last Name:LYONS
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:520 VALLEY VIEW DR STE 200
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6152
Practice Address - Country:US
Practice Address - Phone:309-797-0866
Practice Address - Fax:309-797-0872
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-003003225X00000X
IA00605225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00605OtherIOWA OT LICENSE NUMBER
IL056-003003OtherILLINOIS OT LICENSE NO
IL$$$$$$$$$001Medicaid
ILL72777Medicare PIN
IAI18345Medicare PIN