Provider Demographics
NPI:1508631870
Name:PAYNE, MADISEN KATHERINE (SSW)
Entity Type:Individual
Prefix:
First Name:MADISEN
Middle Name:KATHERINE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:SSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-5240
Mailing Address - Country:US
Mailing Address - Phone:801-499-6276
Mailing Address - Fax:
Practice Address - Street 1:4645 MIDLAND DR STE 2
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:UT
Practice Address - Zip Code:84401-6825
Practice Address - Country:US
Practice Address - Phone:801-332-9139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10376873-3503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty