Provider Demographics
NPI:1740295617
Name:LEAVITT-HALSALL, PAIGE A
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:A
Last Name:LEAVITT-HALSALL
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 1:104 CHARLES ELDRIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347
Mailing Address - Country:US
Mailing Address - Phone:508-947-1683
Mailing Address - Fax:508-947-1684
Practice Address - Street 1:104 CHARLES ELDRIDGE DRIVE
Practice Address - Street 2:TRANQUIL MIND & WELLNESS INC
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347
Practice Address - Country:US
Practice Address - Phone:508-947-1683
Practice Address - Fax:508-947-1684
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAPRN175441163WP0808X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI271408OtherBLUE CROSS
2173937OtherCIGNA
33106235303OtherPACIFICARE
469386OtherTUFTS
1895028OtherMBHP
MAPN0805OtherBLUE CROSS
6NS0687Medicare ID - Type Unspecified