MEDICARE: MARY L WARREN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1273	KY

General Provider Information

NPI Number	:	1336168194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY L WARREN

Provider Business Mailing Address
First Line	:	161 SAINT MATTHEWS AVE
Second Line	:	SUITE 17
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-3145
Country	:	US
Telephone Number	:	502-897-8756
Fax Number	:	502-897-3867

Provider Business Practice Location Address
First Line	:	161 SAINT MATTHEWS AVE
Second Line	:	SUITE 17
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-3145
Country	:	US
Telephone Number	:	502-897-8756
Fax Number	:	502-897-3867

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/08/2007

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