Healthcare Provider Details

I. General information

NPI: 1104247337
Provider Name (Legal Business Name): PAYTONS PLACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2013
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 EAST COOK RD SUITE 100
FORT WAYNE IN
46825
US

IV. Provider business mailing address

2599 COUNTY ROAD 72
AUBURN IN
46706
US

V. Phone/Fax

Practice location:
  • Phone: 260-498-9933
  • Fax:
Mailing address:
  • Phone: 260-498-9933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042225A
License Number StateIN

VIII. Authorized Official

Name: DR. MARLA SOUDER
Title or Position: OWNER/PRESIDENT/PSYCHOLOGIST
Credential: PSY.D., HSPP
Phone: 260-498-9933