Basic Information
| Provider Information | |||||||||
| NPI: | 1619325727 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DFAS-CL/JFLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 626 JOHN PAUL JONES CIR | ||||||||
| Address2: | MENTAL HEALTH TRAINING | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237085000 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 626 JOHN PAUL JONES CIR | ||||||||
| Address2: | MENTAL HEALTH TRAINING | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237085000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579537641 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2016 | ||||||||
| LastUpdateDate: | 05/31/2016 | ||||||||
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| AuthorizedOfficialLastName: | FRANKS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERNSHIP TRAINING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7579537641 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PSY.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | Y | Hospitals | Military Hospital |
No ID Information.