Provider Demographics
NPI:1003552829
Name:PAYNE, ELISABETH ERIN
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:ERIN
Last Name:PAYNE
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 1:1036 SE DOUGLAS AVE.
Mailing Address - Street 2:ROOM CH105A
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470
Mailing Address - Country:US
Mailing Address - Phone:541-391-2636
Mailing Address - Fax:
Practice Address - Street 1:215 SE JACKSON ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3341
Practice Address - Country:US
Practice Address - Phone:541-464-6660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1366697690Medicaid