Provider Demographics
NPI:1366970782
Name:PAYNE, ELLYCE DIANA (MS, NCC, LAPC)
Entity type:Individual
Prefix:
First Name:ELLYCE
Middle Name:DIANA
Last Name:PAYNE
Suffix:
Gender:F
Credentials:MS, NCC, LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2743 FAIRFIELD DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-3721
Mailing Address - Country:US
Mailing Address - Phone:678-522-7832
Mailing Address - Fax:
Practice Address - Street 1:6095 PINE MOUNTAIN RD NW STE 105
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3332
Practice Address - Country:US
Practice Address - Phone:678-217-7529
Practice Address - Fax:770-966-8228
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005656101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health