Healthcare Provider Details

I. General information

NPI: 1669754594
Provider Name (Legal Business Name): VINCENT S WARREN B.S. CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2011
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N 4TH ST
EFFINGHAM IL
62401-3032
US

IV. Provider business mailing address

1200 N 4TH ST
EFFINGHAM IL
62401-3032
US

V. Phone/Fax

Practice location:
  • Phone: 217-347-7179
  • Fax: 217-347-6716
Mailing address:
  • Phone: 217-347-7179
  • Fax: 217-347-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25350
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: