Provider Demographics
NPI:1316010705
Name:PRENTICE, PAIGE K (MM, CASAC)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:K
Last Name:PRENTICE
Suffix:
Gender:F
Credentials:MM, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 INDUCON DR E
Mailing Address - Street 2:
Mailing Address - City:SANBORN
Mailing Address - State:NY
Mailing Address - Zip Code:14132-9014
Mailing Address - Country:US
Mailing Address - Phone:716-731-2030
Mailing Address - Fax:716-731-3010
Practice Address - Street 1:6301 INDUCON DR E
Practice Address - Street 2:
Practice Address - City:SANBORN
Practice Address - State:NY
Practice Address - Zip Code:14132-9014
Practice Address - Country:US
Practice Address - Phone:716-731-2030
Practice Address - Fax:716-731-3010
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10920101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10920OtherCASAC