| Name | Value |
|---|---|
| PROVIDER TYPE | Behavioral Health & Social Service Providers |
| CLASSIFICATION | Psychologist |
| AREA OF SPECIALIZATION | Intellectual & Developmental Disabilities |
| STATUS | Active |
| VA CODE | V010415 |
| X12 CODE | 103TM1800X |
| SPECIALTY CODE | 62 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252363 |
| EFFECTIVE DATE/TIME |
|