Healthcare Provider Details

I. General information

NPI: 1568875193
Provider Name (Legal Business Name): LAUREL PAYNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 EXCHANGE ST
ASTORIA OR
97103-3365
US

IV. Provider business mailing address

9489 E STAR WATER DR
TUCSON AZ
85749-8706
US

V. Phone/Fax

Practice location:
  • Phone: 503-325-5722
  • Fax:
Mailing address:
  • Phone: 541-784-6719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberDO189833
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO189833
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: