Provider Demographics
NPI:1184862666
Name:PAYNE, BRENDA J (CMT)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:J
Last Name:PAYNE
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 CASCADE RD SE STE C
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3808
Mailing Address - Country:US
Mailing Address - Phone:616-610-1097
Mailing Address - Fax:616-940-4594
Practice Address - Street 1:5060 CASCADE RD SE STE C
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3808
Practice Address - Country:US
Practice Address - Phone:616-610-1097
Practice Address - Fax:616-940-4594
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist