Provider Demographics
NPI:1629097274
Name:VA MEDICAL CENTER BATH NY
Entity Type:Organization
Organization Name:VA MEDICAL CENTER BATH NY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:607-664-4305
Mailing Address - Street 1:104 TEXAS LN
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1755
Mailing Address - Country:US
Mailing Address - Phone:607-319-0929
Mailing Address - Fax:
Practice Address - Street 1:76 VETERANS AVE
Practice Address - Street 2:BEHAVIORAL HEALTH ROOM 511D
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-0810
Practice Address - Country:US
Practice Address - Phone:607-664-4305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR94-27P103T00000X, 103TA0400X, 103TB0200X, 103TC0700X, 103TM1800X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty