Provider Demographics
NPI:1053881607
Name:DORN, PAIGE M (MSW, APSW)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:M
Last Name:DORN
Suffix:
Gender:F
Credentials:MSW, APSW
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:M
Other - Last Name:CALMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 22308
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2308
Mailing Address - Country:US
Mailing Address - Phone:920-436-6800
Mailing Address - Fax:920-432-5966
Practice Address - Street 1:626 S IRWIN AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-436-6800
Practice Address - Fax:920-432-5966
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI130905104100000X
WI94431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1053881607Medicaid