| Name | Value |
|---|---|
| PROVIDER TYPE | Clinical Pastoral Ed (Specialty) |
| CLASSIFICATION | Resident |
| STATUS | Inactive |
| DATE INACTIVATED | 2019-10-01 00:00:00 |
| VA CODE | V010602 |
| X12 CODE | 390200000X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5325874 |
| EFFECTIVE DATE/TIME |
|