Provider Demographics
NPI:1427251347
Name:PAYNE, CARRIE L (PTA)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:PAYNE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 WEST AVE S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4783
Mailing Address - Country:US
Mailing Address - Phone:608-785-0940
Mailing Address - Fax:608-392-9898
Practice Address - Street 1:700 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4783
Practice Address - Country:US
Practice Address - Phone:608-785-0940
Practice Address - Fax:608-392-9898
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1390225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36138600Medicaid