Basic Information
| Provider Information | |||||||||
| NPI: | 1114155439 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VA HEALTH CARE SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 795 WILLOW ROAD | ||||||||
| Address2: | |||||||||
| City: | MENLO PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504935000 | ||||||||
| FaxNumber: | 6506172614 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 MIRANDA AVE | ||||||||
| Address2: | |||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943041207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504935000 | ||||||||
| FaxNumber: | 6506172614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 06/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | MYERS | ||||||||
| AuthorizedOfficialFirstName: | DORETHA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 6504935000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | P-LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | P003597 | NC | Y | Hospitals | Psychiatric Hospital |
No ID Information.