Provider Demographics
NPI:1780313437
Name:MBA-HALL, LIDIA P (CDCA)
Entity type:Individual
Prefix:
First Name:LIDIA
Middle Name:P
Last Name:MBA-HALL
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 LAKE CLUB DR STE 106
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-3101
Mailing Address - Country:US
Mailing Address - Phone:614-425-7437
Mailing Address - Fax:
Practice Address - Street 1:2323 LAKE CLUB DR STE 106
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-3101
Practice Address - Country:US
Practice Address - Phone:614-425-7437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH180748101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH180748OtherCHEMICAL DEPENDENCY COUNSELOR ASSISTANT