| Name | Value |
|---|---|
| PROVIDER TYPE | Behavioral Health & Social Service Providers |
| CLASSIFICATION | Psychologist |
| AREA OF SPECIALIZATION | Educational |
| STATUS | Inactive |
| DATE INACTIVATED | 2009-04-22 00:00:00 |
| VA CODE | V010412 |
| X12 CODE | 103TE1000X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252342 |
| EFFECTIVE DATE/TIME |
|