Healthcare Provider Details

I. General information

NPI: 1710608534
Provider Name (Legal Business Name): ANDREA KOBAN PAYNE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/09/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 N OLIVE ST
MEDIA PA
19063-3250
US

IV. Provider business mailing address

221 N OLIVE ST
MEDIA PA
19063-3250
US

V. Phone/Fax

Practice location:
  • Phone: 215-901-3160
  • Fax:
Mailing address:
  • Phone: 215-901-3160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS009059L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: