Provider Demographics
NPI:1841915816
Name:LYON, RENISHA NICOLE (LCMHCA, MDIV, NCC)
Entity type:Individual
Prefix:
First Name:RENISHA
Middle Name:NICOLE
Last Name:LYON
Suffix:
Gender:F
Credentials:LCMHCA, MDIV, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 SKYLARK RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:GA
Mailing Address - Zip Code:31302-9667
Mailing Address - Country:US
Mailing Address - Phone:910-977-3264
Mailing Address - Fax:
Practice Address - Street 1:235 S CHERRY ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-5230
Practice Address - Country:US
Practice Address - Phone:336-355-8084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18138101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health