Provider Demographics
NPI:1487022075
Name:PAGE, AMY DALTON
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DALTON
Last Name:PAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 SHERWOOD PL
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-2521
Mailing Address - Country:US
Mailing Address - Phone:434-509-0208
Mailing Address - Fax:
Practice Address - Street 1:2486 RIVERMONT AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-1549
Practice Address - Country:US
Practice Address - Phone:434-509-0208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-13
Last Update Date:2015-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000656103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst