| Name | Value |
|---|---|
| PROVIDER TYPE | Behavioral Health & Social Service Providers |
| CLASSIFICATION | Counselor |
| AREA OF SPECIALIZATION | Pastoral |
| STATUS | Active |
| VA CODE | V010204 |
| X12 CODE | 101YP1600X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252297 |
| EFFECTIVE DATE/TIME |
|