=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053838763
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD TRACY WARREN II LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2017
-----------------------------------------------------
Last Update Date | 05/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3469 W BOYNTON BEACH BLVD STE 2 PMB 1056
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33436-4639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-299-0136
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5022 VICTORIA CIR
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33409-7850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-602-4554
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW13868
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------