Provider Demographics
NPI:1245508084
Name:LYONS, ROGER JAMES (PSYD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:JAMES
Last Name:LYONS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 E GRANGEVILLE BLVD SPC 71
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-2292
Mailing Address - Country:US
Mailing Address - Phone:719-429-1404
Mailing Address - Fax:
Practice Address - Street 1:860 E GRANGEVILLE BLVD SPC 71
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-2292
Practice Address - Country:US
Practice Address - Phone:719-429-1404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23939103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic