Healthcare Provider Details

I. General information

NPI: 1073139168
Provider Name (Legal Business Name): RYAN CHARLES WARNER PH.D., CRC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5180
US

IV. Provider business mailing address

735A SILVERBERRY CIR SE
ALBUQUERQUE NM
87116-3108
US

V. Phone/Fax

Practice location:
  • Phone: 505-846-3305
  • Fax:
Mailing address:
  • Phone: 708-925-7719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810006905
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: