Healthcare Provider Details

I. General information

NPI: 1477974590
Provider Name (Legal Business Name): DEMAH PAYNE III LPCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2013
Last Update Date: 12/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 TRAWICK RD
RALEIGH NC
27604-3897
US

IV. Provider business mailing address

5221 MALIK DR
DURHAM NC
27703-9375
US

V. Phone/Fax

Practice location:
  • Phone: 919-896-7536
  • Fax:
Mailing address:
  • Phone: 919-302-7695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA10590
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: