Provider Demographics
NPI:1104334929
Name:MCNICHOLAS, LISA M (CDCA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MCNICHOLAS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:ALEXANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:527 N MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-1227
Mailing Address - Country:US
Mailing Address - Phone:330-797-0070
Mailing Address - Fax:330-797-9146
Practice Address - Street 1:527 N MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-1227
Practice Address - Country:US
Practice Address - Phone:330-797-0070
Practice Address - Fax:330-797-9146
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.169481101YA0400X
OH169481324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)