Provider Demographics
NPI:1053503615
Name:PAYNE, MARY J
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
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 1:1890 PARK MARINA DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0961
Mailing Address - Country:US
Mailing Address - Phone:530-241-2200
Mailing Address - Fax:530-241-3200
Practice Address - Street 1:1890 PARK MARINA DR
Practice Address - Street 2:SUITE 105
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0961
Practice Address - Country:US
Practice Address - Phone:530-241-2200
Practice Address - Fax:530-241-3200
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA2976237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA0029760Medicaid