| Name | Value |
|---|---|
| PROVIDER TYPE | Speech, Language and Hearing Service Providers |
| CLASSIFICATION | Fellow, Speech-Language Pathologist |
| STATUS | Active |
| VA CODE | V140704 |
| X12 CODE | 390200000X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5325958 |
| EFFECTIVE DATE/TIME |
|