Provider Demographics
NPI:1619660800
Name:GREAT VALLEY ACADEMY
Entity Type:Organization
Organization Name:GREAT VALLEY ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:209-876-9446
Mailing Address - Street 1:3200 TULLY RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-0811
Mailing Address - Country:US
Mailing Address - Phone:209-876-9446
Mailing Address - Fax:
Practice Address - Street 1:3200 TULLY RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-0811
Practice Address - Country:US
Practice Address - Phone:209-876-9446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty