Provider Demographics
NPI:1629065495
Name:WARNER, MARK S (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:WARNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 53286
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-3286
Mailing Address - Country:US
Mailing Address - Phone:337-261-5151
Mailing Address - Fax:
Practice Address - Street 1:217 E KALISTE SALOOM RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-8513
Practice Address - Country:US
Practice Address - Phone:337-261-5151
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA651103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1985414Medicaid
LAR15268Medicare UPIN
LA1985414Medicaid