Basic Information
| Provider Information | |||||||||
| NPI: | 1992775019 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | USA MEDDAC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EVANS ARMY COMMUNITY HOPSITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | USA MEDDAC EVANS ARMY HOPSITAL | ||||||||
| Address2: | 1650 COCHRANE CIRCLE; ATTN: CREDENTIALS OFFICE | ||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267844 | ||||||||
| FaxNumber: | 7195267984 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 COCHRANE CIR | ||||||||
| Address2: | |||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267844 | ||||||||
| FaxNumber: | 7195267984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | O'RILEY | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7195267155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PSY.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | 1231 | AL | Y | Hospitals | Military Hospital |
No ID Information.