MEDICARE: XYLA BLUE PAYNE LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LW.61661520	WA

General Provider Information

NPI Number	:	1558124933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	XYLA BLUE PAYNE LICSW

Provider Business Mailing Address
First Line	:	2419 S JUDKINS ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98144-3733
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2419 S JUDKINS ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98144-3733
Country	:	US
Telephone Number	:	206-659-1468
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2024
Last Update Date	:	12/09/2025

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