Provider Demographics
NPI:1417647967
Name:LYDE, ODELL
Entity Type:Individual
Prefix:
First Name:ODELL
Middle Name:
Last Name:LYDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3094 W MARKET ST STE 343
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-3626
Mailing Address - Country:US
Mailing Address - Phone:234-334-5589
Mailing Address - Fax:
Practice Address - Street 1:3094 W MARKET ST STE 343
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3626
Practice Address - Country:US
Practice Address - Phone:234-334-5589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator