Provider Demographics
NPI:1477712701
Name:WARNER, KENNETH ROBERT (AAS)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ROBERT
Last Name:WARNER
Suffix:
Gender:M
Credentials:AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 NE 117TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-4022
Mailing Address - Country:US
Mailing Address - Phone:360-566-9112
Mailing Address - Fax:360-993-3047
Practice Address - Street 1:2009 NE 117TH ST STE 101
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-4022
Practice Address - Country:US
Practice Address - Phone:360-566-9112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00005993101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA101YA0400XMedicaid