Healthcare Provider Details

I. General information

NPI: 1235810672
Provider Name (Legal Business Name): JUSTIN HARRISON LYONS CADC-I, QMHA-I, CRM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JUSTIN HARRISON SILVA

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 NE BEACON DR
GRANTS PASS OR
97526-3815
US

IV. Provider business mailing address

PO BOX 1121
ROSEBURG OR
97470-0254
US

V. Phone/Fax

Practice location:
  • Phone: 541-733-4249
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number25-CRM-4079
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500835867
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier500835861
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: