Provider Demographics
NPI:1093184459
Name:PAYNE, AMY (LMT, CMT, BCTMB)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:PAYNE
Suffix:
Gender:F
Credentials:LMT, CMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 LONE INDIAN TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-4521
Mailing Address - Country:US
Mailing Address - Phone:530-416-0440
Mailing Address - Fax:
Practice Address - Street 1:301 HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:STATELINE
Practice Address - State:NV
Practice Address - Zip Code:89449
Practice Address - Country:US
Practice Address - Phone:530-416-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5714225700000X
CA34542225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist