Provider Demographics
NPI:1578226312
Name:WORTMAN, PAIGE (MS, BCBA)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:WORTMAN
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10930 W POTTER RD STE A
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3450
Mailing Address - Country:US
Mailing Address - Phone:262-200-0900
Mailing Address - Fax:
Practice Address - Street 1:10930 W POTTER RD STE A
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3450
Practice Address - Country:US
Practice Address - Phone:262-200-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1274-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst