Provider Demographics
NPI:1710627351
Name:WARREN, MARK THOMAS
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:WARREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 RIVERLAND RD SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-3610
Mailing Address - Country:US
Mailing Address - Phone:866-565-7222
Mailing Address - Fax:877-734-1914
Practice Address - Street 1:190 CHERRY HILL DR
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-3654
Practice Address - Country:US
Practice Address - Phone:866-565-7222
Practice Address - Fax:877-734-1914
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VABACB774446106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician