Provider Demographics
NPI:1811232499
Name:PAYNE, AMANDA ROSE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 E SANTA INEZ AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-1861
Mailing Address - Country:US
Mailing Address - Phone:650-678-1301
Mailing Address - Fax:
Practice Address - Street 1:402 E SANTA INEZ AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-1861
Practice Address - Country:US
Practice Address - Phone:650-678-1301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-07
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21206235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist