Healthcare Provider Details

I. General information

NPI: 1043720576
Provider Name (Legal Business Name): CRYSTAL L PAYNE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2190 GRANT AVE
MCDONOUGH GA
30252-7699
US

IV. Provider business mailing address

2190 GRANT AVE
MCDONOUGH GA
30252-7699
US

V. Phone/Fax

Practice location:
  • Phone: 404-834-7939
  • Fax:
Mailing address:
  • Phone: 404-834-7939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW007335
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMSW008041
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: