Provider Demographics
NPI:1568673747
Name:WARNER, TERRY THEO (MS)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:THEO
Last Name:WARNER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:MR
Other - First Name:TERRY
Other - Middle Name:THEO
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:109 PADDOCK LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-2948
Mailing Address - Country:US
Mailing Address - Phone:910-692-6116
Mailing Address - Fax:
Practice Address - Street 1:109 PADDOCK LN
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-2948
Practice Address - Country:US
Practice Address - Phone:910-692-6116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC402103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107237Medicaid