=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497000111
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINIQUE M PAYNE CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2012
-----------------------------------------------------
Last Update Date | 01/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 911 COLLEGE ST STE 205
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42101-2183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-551-2032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3024 BRENT GRAY TRCE
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42303-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-787-5235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 5441
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 266782
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------