Provider Demographics
NPI:1861989709
Name:MYHRA, PAIGE MARIE (MA, LADC)
Entity type:Individual
Prefix:MS
First Name:PAIGE
Middle Name:MARIE
Last Name:MYHRA
Suffix:
Gender:F
Credentials:MA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 JUNEAU LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-2175
Mailing Address - Country:US
Mailing Address - Phone:763-245-9644
Mailing Address - Fax:
Practice Address - Street 1:207 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-4667
Practice Address - Country:US
Practice Address - Phone:763-367-6080
Practice Address - Fax:763-263-7897
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304801101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)