Provider Demographics
NPI:1972538783
Name:DVA
Entity type:Organization
Organization Name:DVA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTILING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-584-4040
Mailing Address - Street 1:421 NORTH MAIN STREET
Mailing Address - Street 2:VA MEDICAL CENTER
Mailing Address - City:LEEDS
Mailing Address - State:MA
Mailing Address - Zip Code:01053-9764
Mailing Address - Country:US
Mailing Address - Phone:413-582-3038
Mailing Address - Fax:
Practice Address - Street 1:421 N MAIN ST
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:LEEDS
Practice Address - State:MA
Practice Address - Zip Code:01053-9764
Practice Address - Country:US
Practice Address - Phone:413-582-3038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002701283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002701OtherLCSW