=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053790956
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DFAS-CL/JFLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2015
-----------------------------------------------------
Last Update Date | 05/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 JOHN PAUL JONES CIR BLDG 3
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23708-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-953-6744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 JOHN PAUL JONES CIR BLDG 3
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23708-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-953-6744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STAFF PSYCHOLOGIST
-----------------------------------------------------
Name | MRS. MARGOT GARRETT MCGRATH
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 301-442-3867
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 286500000X
-----------------------------------------------------
Taxonomy Name | Military Hospital
-----------------------------------------------------
License Number | 0810005107
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------