Provider Demographics
NPI:1114298304
Name:WORRELLS, PAGE STACEY
Entity Type:Individual
Prefix:
First Name:PAGE
Middle Name:STACEY
Last Name:WORRELLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 SHERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-3037
Mailing Address - Country:US
Mailing Address - Phone:321-634-3688
Mailing Address - Fax:321-504-0955
Practice Address - Street 1:385 SHERWOOD AVE
Practice Address - Street 2:
Practice Address - City:SATELLITE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-3037
Practice Address - Country:US
Practice Address - Phone:321-634-3688
Practice Address - Fax:321-504-0955
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0004433600Medicaid