Provider Demographics
NPI:1235855164
Name:ANDERSON, PAIGE
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2379 E 140TH ST S
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-4844
Mailing Address - Country:US
Mailing Address - Phone:918-752-8239
Mailing Address - Fax:
Practice Address - Street 1:2379 E 140TH ST S
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-4844
Practice Address - Country:US
Practice Address - Phone:918-752-8239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)