Healthcare Provider Details

I. General information

NPI: 1982939930
Provider Name (Legal Business Name): GILBERT ANSON LYON III LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 KIRKMAN ST
LAKE CHARLES LA
70607-4603
US

IV. Provider business mailing address

4105 KIRKMAN ST
LAKE CHARLES LA
70607-4603
US

V. Phone/Fax

Practice location:
  • Phone: 337-475-8022
  • Fax: 337-475-8054
Mailing address:
  • Phone: 337-475-8022
  • Fax: 337-475-8054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10504
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: