Provider Demographics
NPI:1972832798
Name:PINE, PAIGE R (LCSW)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:R
Last Name:PINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 ROCKFORD CT
Mailing Address - Street 2:PO BOX 6459
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3207
Mailing Address - Country:US
Mailing Address - Phone:765-453-4500
Mailing Address - Fax:765-453-4525
Practice Address - Street 1:1531 ROCKFORD CT
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3207
Practice Address - Country:US
Practice Address - Phone:765-453-4500
Practice Address - Fax:765-453-4525
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN225230Medicare PIN
IN100150154AMedicaid