Provider Demographics
NPI:1922130756
Name:WARNER, KIMBERLY L (LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:WARNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KRAFFT RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3565
Mailing Address - Country:US
Mailing Address - Phone:810-985-5125
Mailing Address - Fax:810-985-5127
Practice Address - Street 1:1501 KRAFFT RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3565
Practice Address - Country:US
Practice Address - Phone:810-985-5125
Practice Address - Fax:810-985-5127
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006888101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G46345Medicare ID - Type UnspecifiedBLUE WATER MENTAL HEALTH