Provider Demographics
NPI:1235810672
Name:LYONS, JUSTIN HARRISON (CADC-I, QMHA-I)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:HARRISON
Last Name:LYONS
Suffix:
Gender:M
Credentials:CADC-I, QMHA-I
Other - Prefix:
Other - First Name:JUSTIN
Other - Middle Name:HARRISON
Other - Last Name:SILVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1003 E MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7140
Mailing Address - Country:US
Mailing Address - Phone:541-779-1282
Mailing Address - Fax:541-779-2081
Practice Address - Street 1:1003 E MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7140
Practice Address - Country:US
Practice Address - Phone:541-779-1282
Practice Address - Fax:541-779-2081
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X, 101YM0800X
OR25-CRM-4079175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500835861Medicaid
OR500835867Medicaid