MEDICARE: LAURELLE C WARNER LCSW

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	1041C0700X	Clinical Social Worker	17572	MT
2	1041C0700X	Clinical Social Worker	004048	CT

General Provider Information

NPI Number	:	1922559871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURELLE C WARNER LCSW

Provider Business Mailing Address
First Line	:	2415 MULLAN RD
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59808-1827
Country	:	US
Telephone Number	:	406-549-1050
Fax Number	:	406-549-5215

Provider Business Practice Location Address
First Line	:	2415 MULLAN RD
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59808-1827
Country	:	US
Telephone Number	:	406-549-1050
Fax Number	:	406-549-5215

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

Provider Enumeration Date	:	10/16/2016
Last Update Date	:	10/16/2016

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