Provider Demographics
NPI:1902904477
Name:WARREN, MARY ELLEN (PHD)
Entity Type:Individual
Prefix:PROF
First Name:MARY
Middle Name:ELLEN
Last Name:WARREN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:BREWSTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4348 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-0720
Practice Address - Country:US
Practice Address - Phone:540-769-0976
Practice Address - Fax:540-857-5385
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC633103TC0700X, 103TF0000X, 103TS0200X
VA0810008462103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0409Medicaid
SCPS0409Medicaid
SCQ342324411Medicare PIN