Basic Information
| Provider Information | |||||||||
| NPI: | 1356019285 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | PAIGE | ||||||||
| MiddleName: | MADISON | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3223 LEMMON AVE APT 3117 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752041828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135046255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7777 FOREST LN STE C833 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725664591 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2021 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363LP0808X | 1062377 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.