Provider Demographics
NPI:1023363132
Name:WARNER, ELLEN MARIE
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:WARNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:MARIE
Other - Last Name:SCHALTENBRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1217 WOODBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-3882
Mailing Address - Country:US
Mailing Address - Phone:618-580-8976
Mailing Address - Fax:618-345-5904
Practice Address - Street 1:601 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CASEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62232-1306
Practice Address - Country:US
Practice Address - Phone:618-344-9355
Practice Address - Fax:618-344-9356
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057001621224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant