Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) |
NPI | 1396286761 |
---|---|
Provider Name | Cory Vanderhill |
First Address | Las Vegas, NV 89128-0402 |
Second Address | Las Vegas, NV 89128-0402 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/03/2017 |
Last Update Date | 17/03/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0000143106 | (05) | NV |
1500151870 | HEALTH PLAN OF NEVADA (01) | NV |