Provider Demographics
NPI:1093515603
Name:PAIGE, WILLIS (CSA)
Entity type:Individual
Prefix:
First Name:WILLIS
Middle Name:
Last Name:PAIGE
Suffix:
Gender:
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1169 EASTERN PKWY STE 1124
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1462
Mailing Address - Country:US
Mailing Address - Phone:502-576-6643
Mailing Address - Fax:
Practice Address - Street 1:1169 EASTERN PKWY STE 1124
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1462
Practice Address - Country:US
Practice Address - Phone:502-576-6643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1220450251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health