Healthcare Provider Details

I. General information

NPI: 1760824890
Provider Name (Legal Business Name): LISA RENEE MARR LYON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 WEST ROAD, SUITE 128 CHILDREN'S CLINIC, P.A.
LOS ALAMOS NM
87544
US

IV. Provider business mailing address

3917 WEST ROAD, SUITE 128 LOS ALAMOS CHILDREN'S CLINIC
LOS ALAMOS NM
87544
US

V. Phone/Fax

Practice location:
  • Phone: 505-662-4234
  • Fax:
Mailing address:
  • Phone: 505-662-4234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number306556
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: