Provider Demographics
NPI:1710346903
Name:WARREN, BRENDA MARIE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:MARIE
Last Name:WARREN
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 1:277 MLK BLVD. SUITE 203
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-745-2811
Mailing Address - Fax:478-745-0881
Practice Address - Street 1:106-B OLYMPIA DR.
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093
Practice Address - Country:US
Practice Address - Phone:478-745-2811
Practice Address - Fax:478-745-0881
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAMFT000323106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist