Provider Demographics
NPI:1467552059
Name:PAGE, CHARLES LAVALLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LAVALLE
Last Name:PAGE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 W HARVARD ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2186
Mailing Address - Country:US
Mailing Address - Phone:970-682-1173
Mailing Address - Fax:970-282-1782
Practice Address - Street 1:149 W HARVARD ST
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2186
Practice Address - Country:US
Practice Address - Phone:970-682-1173
Practice Address - Fax:970-282-1782
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1404103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07014046Medicaid
WY113597000Medicaid
CO86506Medicare ID - Type Unspecified