Healthcare Provider Details

I. General information

NPI: 1235810672
Provider Name (Legal Business Name): JUSTIN HARRISON LYONS CADCII QMHAII CRMII
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: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 SW RAMSEY AVE
GRANTS PASS OR
97527-5529
US

IV. Provider business mailing address

1215 SW G ST
GRANTS PASS OR
97526-2544
US

V. Phone/Fax

Practice location:
  • Phone: 541-476-2373
  • Fax:
Mailing address:
  • Phone: 541-476-2373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25-11-20660
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number26-CRM-II-0658
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number26-QMHA-II-000648
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: