Basic Information
| Provider Information | |||||||||
| NPI: | 1790416980 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDLIN | ||||||||
| FirstName: | PAIGE | ||||||||
| MiddleName: | MYSTIQUE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 935 STATE ROUTE VV | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638573822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738885925 | ||||||||
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| Practice Location | |||||||||
| Address1: | 935 STATE ROUTE VV | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638573822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738885925 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2022 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.