Basic Information
| Provider Information | |||||||||
| NPI: | 1306933650 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JONATHAN M. WAINWRIGHT MEMORIAL VA MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | WALLA WALLA VA MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 WAINWRIGHT DR | ||||||||
| Address2: | BUILDING 69 ROOM 230 A | ||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | |||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095255200 | ||||||||
| FaxNumber: | 5095273481 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 WAINWRIGHT DR | ||||||||
| Address2: | BUILDING 69 ROOM 230 A | ||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | |||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095255200 | ||||||||
| FaxNumber: | 5095273481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PREAS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | DARWIN | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED CLINICAL SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 5095255200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSW, LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3031 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.