Healthcare Provider Details

I. General information

NPI: 1437315520
Provider Name (Legal Business Name): TANIA LODGE PHD, PCC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3618 W MARKET ST STE 15
FAIRLAWN OH
44333-2425
US

IV. Provider business mailing address

3618 W MARKET ST STE 16
FAIRLAWN OH
44333-2425
US

V. Phone/Fax

Practice location:
  • Phone: 234-466-0445
  • Fax: 234-466-0359
Mailing address:
  • Phone: 234-466-0445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.0500437
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP.08616
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: