Healthcare Provider Details

I. General information

NPI: 1548249923
Provider Name (Legal Business Name): GORDON J LYONS LSCSW, BCD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EDIS ZAMA/ATSUGI SAGAMIHARA DHA
APO AP
96343
US

IV. Provider business mailing address

9379 W 75TH ST
OVERLAND PARK KS
66204-2231
US

V. Phone/Fax

Practice location:
  • Phone: 315-267-6545
  • Fax:
Mailing address:
  • Phone: 913-250-5189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSCSW 2111
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: