Basic Information
| Provider Information | |||||||||
| NPI: | 1770823700 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VETERANS ADMINSTRATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9600 VETERANS DR | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984930001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535832825 | ||||||||
| FaxNumber: | 2535894035 | ||||||||
| Practice Location | |||||||||
| Address1: | 9600 VETERANS DR | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984930001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535832825 | ||||||||
| FaxNumber: | 2535894035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2013 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEVINE | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | RALEIGH | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2535832826 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LICSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | SC60224505 | WA | Y | Agencies | Case Management |
No ID Information.