MEDICARE: TY WARNER

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	390200000X	Student in an Organized Health Care Education/Training Program
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1811884844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TY WARNER

Provider Business Mailing Address
First Line	:	4850 SE WOODSTOCK BLVD APT 541
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-6143
Country	:	US
Telephone Number	:	509-981-2224
Fax Number	:

Provider Business Practice Location Address
First Line	:	4850 SE WOODSTOCK BLVD APT 541
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-6143
Country	:	US
Telephone Number	:	509-981-2224
Fax Number	:

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

Provider Enumeration Date	:	06/23/2025
Last Update Date	:	06/23/2025

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Directions to “ TY WARNER ” Practice Location

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