Provider Demographics
NPI:1639467624
Name:PAYNE, KEITH EDWARD (LMHC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EDWARD
Last Name:PAYNE
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SPRAGUE AVE # 101
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3900
Mailing Address - Country:US
Mailing Address - Phone:509-956-8125
Mailing Address - Fax:
Practice Address - Street 1:800 SPRAGUE AVE # 101
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3900
Practice Address - Country:US
Practice Address - Phone:509-956-8125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60241742101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health