Provider Demographics
NPI:1740739317
Name:DVORAK, PAIGE
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:DVORAK
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 1:172 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3922
Mailing Address - Country:US
Mailing Address - Phone:307-675-8840
Mailing Address - Fax:
Practice Address - Street 1:172 N MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3922
Practice Address - Country:US
Practice Address - Phone:307-675-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
COLPC.0016540101YP2500X
WYLPC-1937101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health