Provider Demographics
NPI:1699480772
Name:PAYNE, SAM (PSYD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:PAYNE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 W WEBSTER AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3710
Mailing Address - Country:US
Mailing Address - Phone:773-991-3016
Mailing Address - Fax:
Practice Address - Street 1:2835 N SHEFFIELD AVE STE 401
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5084
Practice Address - Country:US
Practice Address - Phone:312-248-9490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010920103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical