Provider Demographics
NPI:1548944960
Name:WARNER, RUSSELL
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:WARNER
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 1:341 BIENTERRA TRL APT 2
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5853
Mailing Address - Country:US
Mailing Address - Phone:815-319-2056
Mailing Address - Fax:
Practice Address - Street 1:341 BIENTERRA TRL APT 2
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5853
Practice Address - Country:US
Practice Address - Phone:815-319-2056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health