Provider Demographics
NPI:1194055467
Name:LAVELLE, LISA A (MED, LSW, LICDC-CS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:LAVELLE
Suffix:
Gender:F
Credentials:MED, LSW, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 POWHATAN AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1916
Mailing Address - Country:US
Mailing Address - Phone:614-323-2743
Mailing Address - Fax:
Practice Address - Street 1:4998 W BROAD ST STE 104
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1647
Practice Address - Country:US
Practice Address - Phone:614-754-8051
Practice Address - Fax:614-319-6123
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-07
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLSW # S.0011653104100000X
OHLICDC # 933526101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker