Provider Demographics
NPI:1487694303
Name:PAGE, MARY WILLIS (MA LPA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:WILLIS
Last Name:PAGE
Suffix:
Gender:F
Credentials:MA LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 MAHALEY AVE
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2448
Mailing Address - Country:US
Mailing Address - Phone:704-213-1099
Mailing Address - Fax:704-919-5381
Practice Address - Street 1:165 MAHALEY AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2448
Practice Address - Country:US
Practice Address - Phone:704-213-1099
Practice Address - Fax:704-919-5381
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2021-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1246103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107050Medicaid
NC046G7OtherNC BCBS