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General NPI Number Information
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NPI Number | 1194976274
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Entity Type | Organization
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Legal Business Name | DEPARTMENT OF VETERANS AFFAIRS
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Dates
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Enumeration Date | 10/07/2008
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Last Update Date | 10/07/2008
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Provider Practice Location Address
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Address Line | 3372 STATE ROUTE 11
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City | MALONE
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State | NY
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Zip | 12953-4712
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Country | US
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Telephone | 518-483-1529
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Fax |
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Provider Business Mailing Address
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Address Line | 3372 STATE ROUTE 11
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City | MALONE
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State | NY
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Zip | 12953-4712
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Country | US
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Telephone | 518-483-1529
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Fax |
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Authorized Official
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Title or Position | ACTING BH IN PRIMARY CARE LEAD
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Name | MRS. JAMIE ELLIS
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Credential | NPP
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Telephone | 518-626-5404
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 069540
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License Number State | NY
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