Provider Demographics
NPI:1023508066
Name:PAYNE, MIKAILA R (CDCA)
Entity type:Individual
Prefix:
First Name:MIKAILA
Middle Name:R
Last Name:PAYNE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-1454
Mailing Address - Country:US
Mailing Address - Phone:740-935-2790
Mailing Address - Fax:
Practice Address - Street 1:345 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-1780
Practice Address - Country:US
Practice Address - Phone:740-288-3767
Practice Address - Fax:740-288-1111
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.166753101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)