Provider Demographics
NPI:1376157115
Name:WALLACE, PAIGE (MA ED, CT, CDCA)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA ED, CT, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 MUNSON ST NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2981
Mailing Address - Country:US
Mailing Address - Phone:330-915-2907
Mailing Address - Fax:513-873-1567
Practice Address - Street 1:4200 MUNSON ST NW
Practice Address - Street 2:SUITE A
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2981
Practice Address - Country:US
Practice Address - Phone:330-915-2907
Practice Address - Fax:330-915-2958
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OHC.2002917101YP2500X
OHE.2303295101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health