Healthcare Provider Details

I. General information

NPI: 1356420236
Provider Name (Legal Business Name): SALLY J. WARNICK L.I.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTHSTAR PLAZA STATE HWY 522 SUITE 67A
EL PRADO NM
87529
US

IV. Provider business mailing address

PO BOX 2629
TAOS NM
87571-2629
US

V. Phone/Fax

Practice location:
  • Phone: 505-779-0738
  • Fax:
Mailing address:
  • Phone: 505-779-0738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-4486
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: