=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073807038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY WARREN MS, LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2011
-----------------------------------------------------
Last Update Date | 12/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 ROBERTSON AVE
-----------------------------------------------------
City | WORLAND
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82401-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-707-7924
-----------------------------------------------------
Fax | 402-707-7924
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1413 CHARLES AVE
-----------------------------------------------------
City | WORLAND
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82401-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-707-7924
-----------------------------------------------------
Fax | 402-707-7924
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | PPC-592
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC-1317
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------