Basic Information
| Provider Information | |||||||||
| NPI: | 1104149947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTMENT OF VETERAN AFFAIRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 795 WILLOW RD | ||||||||
| Address2: | (180D) | ||||||||
| City: | MENLO PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940252539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504935000 | ||||||||
| FaxNumber: | 6506176709 | ||||||||
| Practice Location | |||||||||
| Address1: | 795 WILLOW RD | ||||||||
| Address2: | (180D) | ||||||||
| City: | MENLO PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940252539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504935000 | ||||||||
| FaxNumber: | 6506176709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2010 | ||||||||
| LastUpdateDate: | 03/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | CABARDO | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | NOVEDA | ||||||||
| AuthorizedOfficialTitleorPosition: | SOCIAL WORKER CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6504935000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | ASW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | ASW22448 | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | ASW22448 | 01 | CA | ASSOCIATE CLINICAL SOCIAL WORKER | OTHER |