=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972538783
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DVA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 N MAIN ST VA MEDICAL CENTER
-----------------------------------------------------
City | LEEDS
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01053-9764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-582-3038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 421 NORTH MAIN STREET VA MEDICAL CENTER
-----------------------------------------------------
City | LEEDS
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01053-9764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-582-3038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTILING COORDINATOR
-----------------------------------------------------
Name | MS. DENISE CAVANAUGH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 413-584-4040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number | 002701
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------