| Name | Value |
|---|---|
| PROVIDER TYPE | Behavioral Health and Social Service |
| CLASSIFICATION | Psychoanalyst |
| AREA OF SPECIALIZATION | Associate |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-04-02 00:00:00 |
| VA CODE | V010302 |
| X12 CODE | 103SA1400N |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252414 |
| EFFECTIVE DATE/TIME |
|