Provider Demographics
NPI:1518490838
Name:PAYNE, NICOLE DENISE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DENISE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DENISE
Other - Last Name:OREE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12010 LINWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-1108
Mailing Address - Country:US
Mailing Address - Phone:313-865-1500
Mailing Address - Fax:313-867-1477
Practice Address - Street 1:245 PITKIN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-3737
Practice Address - Country:US
Practice Address - Phone:313-865-1500
Practice Address - Fax:313-867-1477
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA820202101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)