Provider Demographics
NPI:1366193807
Name:LYONS, MARY SUSAN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:LYONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 W CLEBURNE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-6812
Mailing Address - Country:US
Mailing Address - Phone:817-876-9185
Mailing Address - Fax:
Practice Address - Street 1:7401 W CLEBURNE RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-6812
Practice Address - Country:US
Practice Address - Phone:817-876-9185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83754101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional