Basic Information
| Provider Information | |||||||||
| NPI: | 1083015267 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VA EASTERN KANSAS HEALTH CARE SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DWIGHT D. EISENHOWER VA MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4101 S 4TH ST | ||||||||
| Address2: | MAIN HOSPITAL, A2, ROOM A629 | ||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660485014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136822000 | ||||||||
| FaxNumber: | 9137584277 | ||||||||
| Practice Location | |||||||||
| Address1: | 4101 S 4TH ST | ||||||||
| Address2: | MAIN HOSPITAL, A2, ROOM A629 | ||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660485014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136822000 | ||||||||
| FaxNumber: | 9137584277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2014 | ||||||||
| LastUpdateDate: | 09/08/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GADDY | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 9136822000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEPARTMENT OF VETERANS AFFAIRS | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 2244 | KS | Y | Agencies | Community/Behavioral Health |
No ID Information.