Provider Demographics
NPI:1447615794
Name:PAIGE, GLENN
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:PAIGE
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 1:200 MEMORIAL AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5726
Mailing Address - Country:US
Mailing Address - Phone:410-871-7608
Mailing Address - Fax:
Practice Address - Street 1:200 MEMORIAL AVENUE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157
Practice Address - Country:US
Practice Address - Phone:410-871-7608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16078101YP2500X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No282N00000XHospitalsGeneral Acute Care Hospital