Provider Demographics
NPI:1194976274
Name:DEPARTMENT OF VETERANS AFFAIRS
Entity type:Organization
Organization Name:DEPARTMENT OF VETERANS AFFAIRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING BH IN PRIMARY CARE LEAD
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:NPP
Authorized Official - Phone:518-626-5404
Mailing Address - Street 1:3372 STATE ROUTE 11
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-4712
Mailing Address - Country:US
Mailing Address - Phone:518-483-1529
Mailing Address - Fax:
Practice Address - Street 1:3372 STATE ROUTE 11
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-4712
Practice Address - Country:US
Practice Address - Phone:518-483-1529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069540251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health