Provider Demographics
NPI:1376157115
Name:WALLACE, PAIGE (LPCC-S, CCATP)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPCC-S, CCATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4522 FULTON DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2332
Mailing Address - Country:US
Mailing Address - Phone:330-915-2907
Mailing Address - Fax:330-915-2958
Practice Address - Street 1:4522 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2332
Practice Address - Country:US
Practice Address - Phone:330-915-2907
Practice Address - Fax:330-915-2958
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2303295-SUPV101Y00000X, 101YP2500X, 101YM0800X
OHE.2303295101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0420288Medicaid