Provider Demographics
NPI:1629612601
Name:PAGE, PHYLLIS DENISE
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:DENISE
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 1:164 HOWARD DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-8049
Mailing Address - Country:US
Mailing Address - Phone:276-340-9136
Mailing Address - Fax:
Practice Address - Street 1:315 HOSPITAL DR STE 204A
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1927
Practice Address - Country:US
Practice Address - Phone:276-340-9136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT63352202172A00000X
VA0732004950101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172A00000XOther Service ProvidersDriver