Provider Demographics
NPI:1871829895
Name:PAYNE, TERRY RAY (LISW-S, LCSW)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:RAY
Last Name:PAYNE
Suffix:
Gender:M
Credentials:LISW-S, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 NILLES RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-7206
Mailing Address - Country:US
Mailing Address - Phone:513-939-0300
Mailing Address - Fax:513-939-0310
Practice Address - Street 1:1251 NILLES RD
Practice Address - Street 2:SUITE 5
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-7206
Practice Address - Country:US
Practice Address - Phone:513-939-0300
Practice Address - Fax:513-939-0310
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005930A1041C0700X
OHI.0009259-S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH214910Medicare PIN