Provider Demographics
NPI:1144501776
Name:PAYNE, GENEVIEVE ROSE (MFT)
Entity type:Individual
Prefix:MRS
First Name:GENEVIEVE
Middle Name:ROSE
Last Name:PAYNE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 SOLANO AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-2220
Mailing Address - Country:US
Mailing Address - Phone:510-984-6211
Mailing Address - Fax:
Practice Address - Street 1:1715 SOLANO AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-2220
Practice Address - Country:US
Practice Address - Phone:510-984-6211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2015-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81820106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist