Provider Demographics
NPI:1588794572
Name:WARREN, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WARREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2238 BREWERS LNDG
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-4306
Mailing Address - Country:US
Mailing Address - Phone:901-210-0702
Mailing Address - Fax:
Practice Address - Street 1:2670 UNION AVENUE EXT
Practice Address - Street 2:STE 1224
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-4416
Practice Address - Country:US
Practice Address - Phone:901-270-4084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
TN56611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker