Provider Demographics
NPI:1619549656
Name:HOBBS, SHYLA MARIE (LCDC 3)
Entity type:Individual
Prefix:
First Name:SHYLA
Middle Name:MARIE
Last Name:HOBBS
Suffix:
Gender:F
Credentials:LCDC 3
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5649 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:MENTOR ON THE LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44060
Mailing Address - Country:US
Mailing Address - Phone:216-849-4963
Mailing Address - Fax:
Practice Address - Street 1:5649 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MENTOR ON THE LAKE
Practice Address - State:OH
Practice Address - Zip Code:44060-4406
Practice Address - Country:US
Practice Address - Phone:216-849-4963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-10
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OH0002565175T00000X
OHLCDCIII.162761101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0451784Medicaid