Provider Demographics
NPI:1972319820
Name:PAYNE, BROOKE DIANE (LCSW, CPSC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:DIANE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:LCSW, CPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W BANK ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-3279
Mailing Address - Country:US
Mailing Address - Phone:804-862-8002
Mailing Address - Fax:
Practice Address - Street 1:20 W BANK ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-3279
Practice Address - Country:US
Practice Address - Phone:804-862-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040175321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical