Healthcare Provider Details

I. General information

NPI: 1811127350
Provider Name (Legal Business Name): MR. MICHAEL PAYNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3270 KERNER BLVD
SAN RAFAEL CA
94901-4840
US

IV. Provider business mailing address

3270 KERNER BLVD
SAN RAFAEL CA
94901-4840
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-2305
  • Fax: 415-473-2305
Mailing address:
  • Phone: 415-473-2305
  • Fax: 415-473-3850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: