Provider Demographics
NPI:1174017974
Name:MACK, PAIGE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11907 W COUNTY ROAD 10
Mailing Address - Street 2:
Mailing Address - City:ALVADA
Mailing Address - State:OH
Mailing Address - Zip Code:44802-9701
Mailing Address - Country:US
Mailing Address - Phone:419-619-5094
Mailing Address - Fax:
Practice Address - Street 1:27 ST LAWRENCE DR STE 104
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8313
Practice Address - Country:US
Practice Address - Phone:419-455-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.13466235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist