Provider Demographics
NPI:1902689631
Name:PAGE, MICHELLE EILEEN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:EILEEN
Last Name:PAGE
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 1:5764 NW 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-4034
Mailing Address - Country:US
Mailing Address - Phone:954-415-8889
Mailing Address - Fax:
Practice Address - Street 1:5764 NW 120TH AVE
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-4034
Practice Address - Country:US
Practice Address - Phone:954-415-8889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24043101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health