Provider Demographics
NPI:1720680556
Name:CRACE, PAYTEN ANN
Entity type:Individual
Prefix:
First Name:PAYTEN
Middle Name:ANN
Last Name:CRACE
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 1:2730 DAVE WARD DR APT 525
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6477
Mailing Address - Country:US
Mailing Address - Phone:501-286-9954
Mailing Address - Fax:
Practice Address - Street 1:1301 MUSEUM RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4739
Practice Address - Country:US
Practice Address - Phone:501-358-6535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR106S00000XMedicaid