Provider Demographics
NPI:1851533640
Name:WARNER, RUSS (LISAC)
Entity Type:Individual
Prefix:
First Name:RUSS
Middle Name:
Last Name:WARNER
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4735 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-5610
Mailing Address - Country:US
Mailing Address - Phone:520-991-5561
Mailing Address - Fax:520-888-7254
Practice Address - Street 1:4735 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-5610
Practice Address - Country:US
Practice Address - Phone:520-991-5561
Practice Address - Fax:520-888-7254
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1077101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1077OtherLISAC