MEDICARE: LYON HALL SERVICES, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	101YM0800X	Mental Health Counselor
3	103TC1900X	Counseling Psychologist
4	1041C0700X	Clinical Social Worker
5	106H00000X	Marriage & Family Therapist
6	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1225596612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYON HALL SERVICES, LLC

Provider Business Mailing Address
First Line	:	3411 W DIVERSEY AVE STE 5-6
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1245
Country	:	US
Telephone Number	:	773-888-2016
Fax Number	:

Provider Business Practice Location Address
First Line	:	3411 W DIVERSEY AVE STE 5-6
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1245
Country	:	US
Telephone Number	:	773-888-2016
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MOLLY LYON HALL
Credential	:	LCPC
Telephone Number	:	773-888-2016

Provider Enumeration Date	:	03/05/2019
Last Update Date	:	03/05/2019

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