Provider Demographics
NPI:1730917675
Name:ACTING OUT LOUD THERAPY, LLC
Entity type:Organization
Organization Name:ACTING OUT LOUD THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SHANTA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD-LPC, CAGCS
Authorized Official - Phone:818-442-9055
Mailing Address - Street 1:1050 JOHNNIE DODDS BLVD UNIT 1283
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29465-2862
Mailing Address - Country:US
Mailing Address - Phone:818-442-9055
Mailing Address - Fax:
Practice Address - Street 1:1156 BOWMAN RD UNIT 207
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3858
Practice Address - Country:US
Practice Address - Phone:818-442-9055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC2334Medicaid