Provider Demographics
NPI:1316456122
Name:PAYNE, KELLI RUTH
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:RUTH
Last Name:PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 W CARMEL DR STE 120
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5501
Mailing Address - Country:US
Mailing Address - Phone:1317-569-5433
Mailing Address - Fax:317-569-1767
Practice Address - Street 1:615 W CARMEL DR STE 120
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5501
Practice Address - Country:US
Practice Address - Phone:131-756-9543
Practice Address - Fax:317-569-5433
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001977A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist