Healthcare Provider Details

I. General information

NPI: 1629097274
Provider Name (Legal Business Name): VA MEDICAL CENTER BATH NY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 VETERANS AVE BEHAVIORAL HEALTH ROOM 511D
BATH NY
14810-0810
US

IV. Provider business mailing address

104 TEXAS LN
ITHACA NY
14850-1755
US

V. Phone/Fax

Practice location:
  • Phone: 607-664-4305
  • Fax:
Mailing address:
  • Phone: 607-319-0929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number94-27P
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number94-27P
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number94-27P
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number94-27P
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number94-27P
License Number StateAR
# 6
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number94-27P
License Number StateAR

VIII. Authorized Official

Name: DR. MARK W LAWSON
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 607-664-4305