Healthcare Provider Details

I. General information

NPI: 1497716138
Provider Name (Legal Business Name): ALISSA D LYON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4501
US

IV. Provider business mailing address

500 W. FORT ST. VA MEDICAL CENTER (B116)
BOISE ID
83702-4598
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1000
  • Fax: 208-422-1496
Mailing address:
  • Phone: 208-422-1000
  • Fax: 208-422-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW25640
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: