Provider Demographics
NPI:1679609705
Name:LYONS, RUSSEL (ATC)
Entity type:Individual
Prefix:
First Name:RUSSEL
Middle Name:
Last Name:LYONS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14226 S 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2318
Mailing Address - Country:US
Mailing Address - Phone:708-590-6387
Mailing Address - Fax:
Practice Address - Street 1:1611 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:312-237-1248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0021072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer