Provider Demographics
NPI:1447977228
Name:CORTEZ, PAIGE SUZANNA
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:SUZANNA
Last Name:CORTEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 HENRY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29404-2222
Mailing Address - Country:US
Mailing Address - Phone:925-642-0575
Mailing Address - Fax:
Practice Address - Street 1:1711 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-9320
Practice Address - Country:US
Practice Address - Phone:925-642-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11521189106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician