MEDICARE: MICHAEL 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	101Y00000X	Counselor	CTB-2023-0545	NM

General Provider Information

NPI Number	:	1679315303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL WARREN

Provider Business Mailing Address
First Line	:	PO BOX 1490
Second Line	:
City	:	FORT DEFIANCE
State	:	AZ
Zip	:	86504-1490
Country	:	US
Telephone Number	:	928-729-4012
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 1490
Second Line	:
City	:	FORT DEFIANCE
State	:	AZ
Zip	:	86504-1490
Country	:	US
Telephone Number	:	928-729-4012
Fax Number	:

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

Provider Enumeration Date	:	06/12/2024
Last Update Date	:	06/12/2024

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