1356420236 NPI number — SALLY J. WARNICK L.I.S.W.

Table of content: SALLY J. WARNICK L.I.S.W. (NPI 1356420236)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356420236 NPI number — SALLY J. WARNICK L.I.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WARNICK
Provider First Name:
SALLY
Provider Middle Name:
J.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.I.S.W.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356420236
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2629
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87571-2629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-779-0738
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NORTHSTAR PLAZA STATE HWY 522
Provider Second Line Business Practice Location Address:
SUITE 67A
Provider Business Practice Location Address City Name:
EL PRADO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-779-0738
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C-4486 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 047127 . This is a "VALUE OPTIONS MENTAL HEAL" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 00JP22 . This is a "BCBS OF NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 59635533 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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