Provider Demographics
NPI:1053882621
Name:PAYNE, MARY (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PAYNE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 RAVEN DR
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77808-9717
Mailing Address - Country:US
Mailing Address - Phone:281-682-6121
Mailing Address - Fax:
Practice Address - Street 1:207 ROCK PRAIRIE RD STE A1
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8777
Practice Address - Country:US
Practice Address - Phone:979-229-7636
Practice Address - Fax:979-694-7337
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX608271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty