Provider Demographics
NPI:1598476756
Name:WALTERS, PAIGE
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:
Other - Last Name:GASPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8512
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-1512
Mailing Address - Country:US
Mailing Address - Phone:707-341-6626
Mailing Address - Fax:
Practice Address - Street 1:1128 EDWARDS AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-8801
Practice Address - Country:US
Practice Address - Phone:707-303-8433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10234101YM0800X
CA127727106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health