Provider Demographics
NPI:1558637959
Name:WARNER, CANDIS MARLO
Entity Type:Individual
Prefix:DR
First Name:CANDIS
Middle Name:MARLO
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 1:8120 MOORSBRIDGE RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-7414
Mailing Address - Country:US
Mailing Address - Phone:269-598-8942
Mailing Address - Fax:269-323-0358
Practice Address - Street 1:8120 MOORSBRIDGE RD
Practice Address - Street 2:SUITE D
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-7414
Practice Address - Country:US
Practice Address - Phone:269-598-8942
Practice Address - Fax:269-323-0358
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007981103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist