| Name | Value |
|---|---|
| PROVIDER TYPE | Behavioral Health and Social Service |
| CLASSIFICATION | Psychoanalyst |
| AREA OF SPECIALIZATION | Affiliate |
| STATUS | Inactive |
| DATE INACTIVATED | 2005-11-15 00:00:00 |
| VA CODE | V010301 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252426 |
| EFFECTIVE DATE/TIME |
|