Provider Demographics
NPI:1306131636
Name:WILSON, PAIGE (PHD, LP, HSPP)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD, LP, HSPP
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:
Other - Last Name:MISSION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, LP, HSPP
Mailing Address - Street 1:3960 PATIENT CARE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4292
Mailing Address - Country:US
Mailing Address - Phone:517-887-9801
Mailing Address - Fax:517-887-9826
Practice Address - Street 1:3960 PATIENT CARE DR STE 104
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4292
Practice Address - Country:US
Practice Address - Phone:517-887-9801
Practice Address - Fax:517-887-9826
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3593103G00000X
CO6286103T00000X
MI6301019175103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1306131636Medicaid