Healthcare Provider Details

I. General information

NPI: 1346888468
Provider Name (Legal Business Name): PAIGE NICKOL LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 W 3RD ST
DAYTON OH
45402-1814
US

IV. Provider business mailing address

141 W 3RD ST
DAYTON OH
45402-1814
US

V. Phone/Fax

Practice location:
  • Phone: 937-818-9121
  • Fax: 937-222-0610
Mailing address:
  • Phone: 937-818-9121
  • Fax: 937-222-0610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2208296
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: