Provider Demographics
NPI:1780041061
Name:MUTTON, PAIGE
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:MUTTON
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 1:10380 NOONTIDE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1066
Mailing Address - Country:US
Mailing Address - Phone:702-822-0500
Mailing Address - Fax:
Practice Address - Street 1:911 N BUFFALO DR
Practice Address - Street 2:213
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0379
Practice Address - Country:US
Practice Address - Phone:702-942-1774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV145600645Medicaid