Provider Demographics
NPI:1356420236
Name:WARNICK, SALLY J (LISW)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:J
Last Name:WARNICK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2629
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-2629
Mailing Address - Country:US
Mailing Address - Phone:505-779-0738
Mailing Address - Fax:
Practice Address - Street 1:NORTHSTAR PLAZA STATE HWY 522
Practice Address - Street 2:SUITE 67A
Practice Address - City:EL PRADO
Practice Address - State:NM
Practice Address - Zip Code:87529
Practice Address - Country:US
Practice Address - Phone:505-779-0738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-44861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM047127OtherVALUE OPTIONS MENTAL HEAL
NM00JP22OtherBCBS OF NM
NM59635533Medicaid