Provider Demographics
NPI:1487144754
Name:FORMANEK, PAIGE (LISW)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:FORMANEK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17650 EASTBROOK TRL
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023-5660
Mailing Address - Country:US
Mailing Address - Phone:440-708-4768
Mailing Address - Fax:
Practice Address - Street 1:25000 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-4105
Practice Address - Country:US
Practice Address - Phone:440-708-4768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-13
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.22033541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH166066OtherOHIO CHEMICAL DEPENDENCY BOARD