Provider Demographics
NPI:1447067012
Name:PAYNE, KORI LARRISA
Entity type:Individual
Prefix:
First Name:KORI
Middle Name:LARRISA
Last Name:PAYNE
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 1:3855 DUNHAGAN RD APT 201
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-6660
Mailing Address - Country:US
Mailing Address - Phone:240-812-2045
Mailing Address - Fax:
Practice Address - Street 1:3855 DUNHAGAN RD APT 201
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-6660
Practice Address - Country:US
Practice Address - Phone:240-812-2045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20227101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health