Provider Demographics
NPI:1740417245
Name:PAYNE, RUSSELL K (MED LPC-S)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:K
Last Name:PAYNE
Suffix:
Gender:M
Credentials:MED LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 ENGLISH ST
Mailing Address - Street 2:
Mailing Address - City:GLEN ROSE
Mailing Address - State:TX
Mailing Address - Zip Code:76043-4922
Mailing Address - Country:US
Mailing Address - Phone:817-253-9826
Mailing Address - Fax:
Practice Address - Street 1:1011 GRANBURY ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-5752
Practice Address - Country:US
Practice Address - Phone:817-645-3328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14117101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional