Provider Demographics
NPI:1831495415
Name:U.S. DEPARTMENT OF VETERANS AFFAIRS
Entity Type:Organization
Organization Name:U.S. DEPARTMENT OF VETERANS AFFAIRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRYPHENA
Authorized Official - Middle Name:HUBBARD
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:228-261-0422
Mailing Address - Street 1:15235 SAINT CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2822
Mailing Address - Country:US
Mailing Address - Phone:228-261-0422
Mailing Address - Fax:
Practice Address - Street 1:400 VETERANS AVE
Practice Address - Street 2:T100 (SOCIAL WORK)
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2410
Practice Address - Country:US
Practice Address - Phone:228-523-4550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS340727612OtherVETERAN AFFAIRS HEALTH CARE SYSTEM