=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255608683
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLAS BRANDON WARNER PSY.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2011
-----------------------------------------------------
Last Update Date | 08/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4610 N CLARK ST # 1307
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-4620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-240-5151
-----------------------------------------------------
Fax | 341-689-3474
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4610 N CLARK ST # 1307
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-4620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-240-5151
-----------------------------------------------------
Fax | 341-689-3474
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071008256
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------