Healthcare Provider Details

I. General information

NPI: 1417232034
Provider Name (Legal Business Name): JILL W LYONS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 VANDERBILT AVE
NORTH TONAWANDA NY
14120
US

IV. Provider business mailing address

1500 VANDERBILT AVE
NORTH TONAWANDA NY
14120-1819
US

V. Phone/Fax

Practice location:
  • Phone: 716-807-3707
  • Fax: 716-807-3701
Mailing address:
  • Phone: 716-807-3707
  • Fax: 716-807-3701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number084044-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number58610
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: