Provider Demographics
NPI:1154121556
Name:PAYNE, AMY MICHELLE (PPS)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:PAYNE
Suffix:
Gender:
Credentials:PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-3301
Mailing Address - Country:US
Mailing Address - Phone:209-556-1500
Mailing Address - Fax:
Practice Address - Street 1:2503 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-3301
Practice Address - Country:US
Practice Address - Phone:209-485-0361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220159743103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool