Basic Information
| Provider Information | |||||||||
| NPI: | 1487719456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARLEY | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | RANDOLPH | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1825 MARTHA BERRY BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062955331 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 BROAD ST STE 350 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062952028 | ||||||||
| FaxNumber: | 7062952062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 11/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY002644 | GA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 363240904C | 05 | GA | MEDICAID |