Provider Demographics
NPI:1588681142
Name:DIANE L PAYNE PHD PA
Entity Type:Organization
Organization Name:DIANE L PAYNE PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-222-3429
Mailing Address - Street 1:3111 SPRINGBANK LN
Mailing Address - Street 2:SUITE I
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3372
Mailing Address - Country:US
Mailing Address - Phone:704-540-0625
Mailing Address - Fax:
Practice Address - Street 1:3111 SPRINGBANK LN
Practice Address - Street 2:SUITE I
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3372
Practice Address - Country:US
Practice Address - Phone:704-540-0625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1615103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2812489AMedicare PIN