Provider Demographics
NPI:1376790915
Name:SPACKMAN, PAIGE (MS,)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:SPACKMAN
Suffix:
Gender:F
Credentials:MS,
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:SPACKMAN
Other - Last Name:SIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:16615 S 15TH LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85045-0776
Mailing Address - Country:US
Mailing Address - Phone:480-718-5893
Mailing Address - Fax:
Practice Address - Street 1:16615 S 15TH LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85045-0776
Practice Address - Country:US
Practice Address - Phone:480-718-5893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7770103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool