Provider Demographics
NPI:1811388200
Name:WARREN, LAURIE
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
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 1:2911 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2715
Mailing Address - Country:US
Mailing Address - Phone:707-527-7032
Mailing Address - Fax:707-527-7960
Practice Address - Street 1:2911 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2715
Practice Address - Country:US
Practice Address - Phone:707-527-7032
Practice Address - Fax:707-527-7960
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-10444103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst