| Name | Value |
|---|---|
| PROVIDER TYPE | Behavioral Health & Social Service Providers |
| CLASSIFICATION | Clinical Neuropsychologist |
| AREA OF SPECIALIZATION | Clinical |
| STATUS | Inactive |
| DATE INACTIVATED | 2009-04-22 00:00:00 |
| VA CODE | V010402 |
| X12 CODE | 103GC0700X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252315 |
| EFFECTIVE DATE/TIME |
|