Provider Demographics
NPI:1851762009
Name:WARREN BEHAVIORAL CARE
Entity Type:Organization
Organization Name:WARREN BEHAVIORAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:FERNELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-808-8991
Mailing Address - Street 1:201 REGENCY CT
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1179
Mailing Address - Country:US
Mailing Address - Phone:334-673-8869
Mailing Address - Fax:
Practice Address - Street 1:201 REGENCY CT
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1179
Practice Address - Country:US
Practice Address - Phone:334-673-8869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3455101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051532779OtherMEDICARE
AL51532779OtherBLUE CROSS AND BLUE SHIELD
AL529927710Medicaid