Provider Demographics
NPI:1154637072
Name:WARNER, MICHAEL (COTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WARNER
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMER CITY
Mailing Address - State:IL
Mailing Address - Zip Code:61842-1212
Mailing Address - Country:US
Mailing Address - Phone:309-928-2619
Mailing Address - Fax:
Practice Address - Street 1:1790 S FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-4010
Practice Address - Country:US
Practice Address - Phone:217-429-2551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057001557224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant