Healthcare Provider Details

I. General information

NPI: 1083015267
Provider Name (Legal Business Name): VA EASTERN KANSAS HEALTH CARE SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 S 4TH ST MAIN HOSPITAL, A2, ROOM A629
LEAVENWORTH KS
66048-5014
US

IV. Provider business mailing address

4101 S 4TH ST MAIN HOSPITAL, A2, ROOM A629
LEAVENWORTH KS
66048-5014
US

V. Phone/Fax

Practice location:
  • Phone: 913-682-2000
  • Fax: 913-758-4277
Mailing address:
  • Phone: 913-682-2000
  • Fax: 913-758-4277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2244
License Number StateKS

VIII. Authorized Official

Name: DR. MELINDA ANN GADDY
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 913-682-2000