Provider Demographics
NPI:1821818022
Name:PAYNE, KYLE (LAC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:PAYNE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N COLLEGE AVE APT 1070
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85288-0185
Mailing Address - Country:US
Mailing Address - Phone:847-989-6976
Mailing Address - Fax:
Practice Address - Street 1:6245 N 24TH PKWY # A208
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-2024
Practice Address - Country:US
Practice Address - Phone:602-492-2594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-12
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-23043101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health