Provider Demographics
NPI:1609836337
Name:PAYNE, CARL L (MSED)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:L
Last Name:PAYNE
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 MILL ST
Mailing Address - Street 2:SUITE A2
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-1041
Mailing Address - Country:US
Mailing Address - Phone:570-271-0966
Mailing Address - Fax:570-271-1995
Practice Address - Street 1:516 MILL ST
Practice Address - Street 2:SUITE A2
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-1041
Practice Address - Country:US
Practice Address - Phone:570-271-0966
Practice Address - Fax:570-271-1995
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002610L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA009376Medicare ID - Type Unspecified