Basic Information
| Provider Information | |||||||||
| NPI: | 1225063704 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTMENT OF VETERANS AFFAIRS, VA LONG BEACH HEALTHCARE SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 E 7TH ST | ||||||||
| Address2: | SCI/D 07/128 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908225201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628265759 | ||||||||
| FaxNumber: | 5628265718 | ||||||||
| Practice Location | |||||||||
| Address1: | 5901 E 7TH ST | ||||||||
| Address2: | SCI/D 07/128 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908225201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628265759 | ||||||||
| FaxNumber: | 5628265718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LUNDBERG | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED CLINICAL SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 5628265759 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QV0200X | LCS19256 | CA | X | Ambulatory Health Care Facilities | Clinic/Center | VA | 273Y00000X | LCS19256 | CA | X | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | V010100 | 01 | CA | SOCIAL WORKER | OTHER |