Provider Demographics
NPI:1932443702
Name:PAYTON, BERNADINE (MSED, BSW)
Entity Type:Individual
Prefix:MRS
First Name:BERNADINE
Middle Name:
Last Name:PAYTON
Suffix:
Gender:F
Credentials:MSED, BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6602 SELKIRK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46816-4186
Mailing Address - Country:US
Mailing Address - Phone:260-447-5456
Mailing Address - Fax:
Practice Address - Street 1:315 AIRPORT NORTH OFFICE PARK
Practice Address - Street 2:RAJ CLINICS
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825
Practice Address - Country:US
Practice Address - Phone:260-490-8352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN13438Medicaid