=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598026015
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESIREE PAYTON, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2012
-----------------------------------------------------
Last Update Date | 05/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 244 5TH AVE APT 228B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10001-7604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-776-3030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 244 5TH AVE APT 228B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10001-7604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-776-3030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DESIREE PAYTON
-----------------------------------------------------
Credential | MSED
-----------------------------------------------------
Telephone | 917-776-3030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 18093
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------