Provider Demographics
NPI:1851568760
Name:SMITH-WYATT, PAIGE D (NCC)
Entity Type:Individual
Prefix:MRS
First Name:PAIGE
Middle Name:D
Last Name:SMITH-WYATT
Suffix:
Gender:F
Credentials:NCC
Other - Prefix:MISS
Other - First Name:PAIGE
Other - Middle Name:DICKINSON
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NCC
Mailing Address - Street 1:316 2ND AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-5218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:316 2ND AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5218
Practice Address - Country:US
Practice Address - Phone:701-774-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16063101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54516Medicaid
ND54516Medicaid