| Name | Value |
|---|---|
| PROVIDER TYPE | Respiratory, Rehabilitative and Restorative Service |
| CLASSIFICATION | Occupational Therapist |
| AREA OF SPECIALIZATION | Case Management |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-04-02 00:00:00 |
| VA CODE | V130104 |
| X12 CODE | 225XC0400N |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5255408 |
| EFFECTIVE DATE/TIME |
|