=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619660800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT VALLEY ACADEMY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2023
-----------------------------------------------------
Last Update Date | 06/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 TULLY RD
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-0811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-876-9446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3200 TULLY RD
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-0811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-876-9446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERINTENDENT/CEO
-----------------------------------------------------
Name | MR. THOMAS ANDERSON
-----------------------------------------------------
Credential | M.A.
-----------------------------------------------------
Telephone | 209-876-9446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YS0200X
-----------------------------------------------------
Taxonomy Name | School Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------