MEDICARE: LIDIA P MBA-HALL CDCA

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	180748	OH
2	171M00000X	Case Manager/Care Coordinator

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	180748	OTHER	OH	CHEMICAL DEPENDENCY COUNSELOR ASSISTANT

General Provider Information

NPI Number	:	1780313437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIDIA P MBA-HALL CDCA

Provider Business Mailing Address
First Line	:	2323 LAKE CLUB DR STE 106
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-3101
Country	:	US
Telephone Number	:	614-425-7437
Fax Number	:

Provider Business Practice Location Address
First Line	:	2323 LAKE CLUB DR STE 106
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-3101
Country	:	US
Telephone Number	:	614-425-7437
Fax Number	:

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

Provider Enumeration Date	:	06/08/2022
Last Update Date	:	11/18/2023

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