Healthcare Provider Details

I. General information

NPI: 1598476756
Provider Name (Legal Business Name): PAIGE WALTERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAIGE GASPER

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 STONY POINT RD
SANTA ROSA CA
95401-4189
US

IV. Provider business mailing address

PO BOX 8512
SANTA ROSA CA
95407-1512
US

V. Phone/Fax

Practice location:
  • Phone: 707-890-3800
  • Fax:
Mailing address:
  • Phone: 707-341-6626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10234
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number151863
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: