Provider Demographics
NPI:1245699818
Name:ELLER, PAIGE
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:ELLER
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 1:1001 22ND ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-5344
Mailing Address - Country:US
Mailing Address - Phone:941-720-2169
Mailing Address - Fax:
Practice Address - Street 1:677 N WASHINGTON BLVD
Practice Address - Street 2:31
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-4241
Practice Address - Country:US
Practice Address - Phone:941-720-2169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-11
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 7788101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health