Healthcare Provider Details

I. General information

NPI: 1124558614
Provider Name (Legal Business Name): KENNETH ROBERT LYONS MS, SUDP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3639 MLK JR WAY S
SEATTLE WA
98144
US

IV. Provider business mailing address

3639 MLK JR WAY SOUTH
SEATTLE WA
98144
US

V. Phone/Fax

Practice location:
  • Phone: 206-805-8972
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCO60906258
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG60475258
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP61249696
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: