Provider Demographics
NPI:1215569363
Name:WARNER, MICHELLE LYNN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:WARNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 ERIE BLVD W
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2445
Mailing Address - Country:US
Mailing Address - Phone:315-472-7363
Mailing Address - Fax:315-703-2368
Practice Address - Street 1:620 ERIE BLVD W
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-2445
Practice Address - Country:US
Practice Address - Phone:315-472-7363
Practice Address - Fax:315-703-2368
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001639106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist