Provider Demographics
NPI:1669717930
Name:PAGE, CHANDY (LISW)
Entity type:Individual
Prefix:
First Name:CHANDY
Middle Name:
Last Name:PAGE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 VARDEN DR
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-5285
Mailing Address - Country:US
Mailing Address - Phone:803-642-3801
Mailing Address - Fax:
Practice Address - Street 1:116 DRIFTWOOD CIR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-7273
Practice Address - Country:US
Practice Address - Phone:803-599-2594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9236101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAD01AKMedicaid
SC570569761OtherTAX ID