Basic Information
| Provider Information | |||||||||
| NPI: | 1740537299 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VETERANS ADMINISTRATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16111 PLUMMER ST | ||||||||
| Address2: | BUILDING 10 | ||||||||
| City: | SEPULVEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913432036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188917711 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16111 PLUMMER ST | ||||||||
| Address2: | |||||||||
| City: | SEPULVEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913432036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188917711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2012 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAITE | ||||||||
| AuthorizedOfficialFirstName: | MARTHA | ||||||||
| AuthorizedOfficialMiddleName: | STEWART | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF, SOCIAL WORK SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8918917711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0850X | 11181 | PR | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.