Provider Demographics
NPI:1437315520
Name:LODGE, TANIA (PHD, PCC-S)
Entity Type:Individual
Prefix:DR
First Name:TANIA
Middle Name:
Last Name:LODGE
Suffix:
Gender:F
Credentials:PHD, PCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3618 W MARKET ST STE 16
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-2425
Mailing Address - Country:US
Mailing Address - Phone:234-466-0445
Mailing Address - Fax:
Practice Address - Street 1:3618 W MARKET ST STE 15
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-2425
Practice Address - Country:US
Practice Address - Phone:234-466-0445
Practice Address - Fax:234-466-0359
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0500437101YM0800X
OHP.08616103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0214582Medicaid