MEDICARE: DR. TANIA LODGE PHD, PCC-S

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	101YM0800X	Mental Health Counselor	E.0500437	OH
2	103TC0700X	Clinical Psychologist	P.08616	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437315520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TANIA LODGE PHD, PCC-S

Provider Business Mailing Address
First Line	:	3618 W MARKET ST STE 16
Second Line	:
City	:	FAIRLAWN
State	:	OH
Zip	:	44333-2425
Country	:	US
Telephone Number	:	234-466-0445
Fax Number	:

Provider Business Practice Location Address
First Line	:	3618 W MARKET ST STE 15
Second Line	:
City	:	FAIRLAWN
State	:	OH
Zip	:	44333-2425
Country	:	US
Telephone Number	:	234-466-0445
Fax Number	:	234-466-0359

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

Provider Enumeration Date	:	07/29/2008
Last Update Date	:	04/16/2024

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