Provider Demographics
NPI:1952428096
Name:PAYNE, WARREN RUSSELL JR (PHD LICENSED PROFESS)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:RUSSELL
Last Name:PAYNE
Suffix:JR
Gender:M
Credentials:PHD LICENSED PROFESS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 ATALANTA AVENUE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2001
Mailing Address - Country:US
Mailing Address - Phone:314-276-0813
Mailing Address - Fax:
Practice Address - Street 1:875 ATALANTA AVENUE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-2001
Practice Address - Country:US
Practice Address - Phone:314-276-0813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000136101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional