MEDICARE: KORI DETMER CSW-INTERN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	IC-708	NV

General Provider Information

NPI Number	:	1235438086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KORI DETMER CSW-INTERN

Provider Business Mailing Address
First Line	:	4000 E CHARLESTON BLVD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-6681
Country	:	US
Telephone Number	:	702-968-4000
Fax Number	:	702-968-4040

Provider Business Practice Location Address
First Line	:	4000 E CHARLESTON BLVD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-6681
Country	:	US
Telephone Number	:	702-968-4000
Fax Number	:	702-968-4040

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2011
Last Update Date	:	11/14/2011

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Directions to “ KORI DETMER CSW-INTERN” Practice Location

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