Basic Information
| Provider Information | |||||||||
| NPI: | 1407137029 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAYNE | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRIMES | ||||||||
| OtherFirstName: | LEAH | ||||||||
| OtherMiddleName: | PAIGE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPE | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1405 N PIERCE ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722075379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016032147 | ||||||||
| FaxNumber: | 5016030324 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 N PIERCE ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722075379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016032147 | ||||||||
| FaxNumber: | 5016030324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2011 | ||||||||
| LastUpdateDate: | 05/22/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 13-15E | AR | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.