Provider Demographics
NPI:1114923208
Name:PAYNE, MAI LEE (OT)
Entity Type:Individual
Prefix:
First Name:MAI LEE
Middle Name:
Last Name:PAYNE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 S INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-3075
Mailing Address - Country:US
Mailing Address - Phone:706-624-3000
Mailing Address - Fax:706-624-3001
Practice Address - Street 1:365 S INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-3075
Practice Address - Country:US
Practice Address - Phone:706-624-3000
Practice Address - Fax:706-624-3001
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003214225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000891338BMedicaid
GA10037594OtherAMERIGROUP
GA67BBBJ2Medicare ID - Type UnspecifiedMEDICARE PART B
GA52806983002OtherBLUE CROSS/BLUE SHIELD
GA341901OtherWELLCARE