Provider Demographics
NPI:1376243410
Name:WARREN, VIRGINIA (EDS, LPES)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
Credentials:EDS, LPES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4847 FOREST RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-4608
Mailing Address - Country:US
Mailing Address - Phone:803-397-8680
Mailing Address - Fax:
Practice Address - Street 1:1220 PICKENS ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3428
Practice Address - Country:US
Practice Address - Phone:803-250-5239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4773103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool