Provider Demographics
NPI:1194736991
Name:DALLAS VA MEDICAL CENTER
Entity type:Organization
Organization Name:DALLAS VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER II
Authorized Official - Prefix:MS
Authorized Official - First Name:VASHAWN
Authorized Official - Middle Name:KIANGA
Authorized Official - Last Name:CLEMONS
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:214-857-2371
Mailing Address - Street 1:521 JUDY LN
Mailing Address - Street 2:
Mailing Address - City:SEAGOVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75159-1713
Mailing Address - Country:US
Mailing Address - Phone:972-287-9162
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-857-2371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty