Provider Demographics
NPI:1508321365
Name:PAGE, MICHAEL LAWRENCE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:PAGE
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 1:14272 HOOVER ST TRLR 8
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-4317
Mailing Address - Country:US
Mailing Address - Phone:909-658-4821
Mailing Address - Fax:
Practice Address - Street 1:1855 W KATELLA AVE STE 150
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-3432
Practice Address - Country:US
Practice Address - Phone:714-399-3480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health