MEDICARE: LISA A LAVELLE M.ED., LSW, LICDC-CS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	LSW # S.0011653	OH
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	LICDC # 933526	OH

General Provider Information

NPI Number	:	1194055467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA A LAVELLE M.ED., LSW, LICDC-CS

Provider Business Mailing Address
First Line	:	275 POWHATAN AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43204-1916
Country	:	US
Telephone Number	:	614-323-2743
Fax Number	:

Provider Business Practice Location Address
First Line	:	4998 W BROAD ST STE 104
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-1647
Country	:	US
Telephone Number	:	614-754-8051
Fax Number	:	614-319-6123

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2010
Last Update Date	:	01/17/2022

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