Healthcare Provider Details

I. General information

NPI: 1871839308
Provider Name (Legal Business Name): VANESSA PAYNE MS, LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2013
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3819 HARBOR RD 103
CHESAPEAKE BEACH MD
20732-3109
US

IV. Provider business mailing address

PO BOX 980
PRINCE FREDERICK MD
20678-0980
US

V. Phone/Fax

Practice location:
  • Phone: 410-286-0547
  • Fax: 410-286-8950
Mailing address:
  • Phone: 410-535-5400
  • Fax: 410-414-9413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP6930
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: