Healthcare Provider Details

I. General information

NPI: 1144914128
Provider Name (Legal Business Name): LESLIE PAYNE MSW, LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 HERITAGE CENTER DR STE 204
WAKE FOREST NC
27587-9849
US

IV. Provider business mailing address

1764 HERITAGE CENTER DR STE 202
WAKE FOREST NC
27587-4092
US

V. Phone/Fax

Practice location:
  • Phone: 984-235-7596
  • Fax: 984-235-7054
Mailing address:
  • Phone: 984-235-7596
  • Fax: 984-235-7054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP018970
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP018970
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: