Provider Demographics
NPI:1225397698
Name:PAYNE, DAVID RUSSELL (PCC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RUSSELL
Last Name:PAYNE
Suffix:
Gender:M
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 AKIN LN
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41005-9714
Mailing Address - Country:US
Mailing Address - Phone:502-324-7586
Mailing Address - Fax:859-692-1289
Practice Address - Street 1:3920 AKIN LN
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KY
Practice Address - Zip Code:41005-9714
Practice Address - Country:US
Practice Address - Phone:502-324-7586
Practice Address - Fax:859-692-1289
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0800292101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional