Healthcare Provider Details

I. General information

NPI: 1194055467
Provider Name (Legal Business Name): LISA A LAVELLE M.ED., LSW, LICDC-CS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2010
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4998 W BROAD ST STE 104
COLUMBUS OH
43228-1647
US

IV. Provider business mailing address

275 POWHATAN AVE
COLUMBUS OH
43204-1916
US

V. Phone/Fax

Practice location:
  • Phone: 614-754-8051
  • Fax: 614-319-6123
Mailing address:
  • Phone: 614-323-2743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC # 933526
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW # S.0011653
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: