Basic Information
| Provider Information | |||||||||
| NPI: | 1447701362 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAYNE | ||||||||
| FirstName: | AMBRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3015 BROOKDALE AVE | ||||||||
| Address2: | |||||||||
| City: | PARMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441341955 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 22001 FAIRMOUNT BLVD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441184819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169322800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2016 | ||||||||
| LastUpdateDate: | 10/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | S.1600815 | OH | Y | Agencies | Community/Behavioral Health |
No ID Information.