MEDICARE: MITZIE MAY LYONS MA MS LBC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	BH000312	PA

General Provider Information

NPI Number	:	1033781109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITZIE MAY LYONS MA MS LBC

Provider Business Mailing Address
First Line	:	3720 SPRUCE ST STE 295
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-4115
Country	:	US
Telephone Number	:	215-939-7005
Fax Number	:

Provider Business Practice Location Address
First Line	:	222 N MAPLE AVE
Second Line	:
City	:	LANSDOWNE
State	:	PA
Zip	:	19050-1609
Country	:	US
Telephone Number	:	215-939-7005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2021
Last Update Date	:	07/16/2021

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