Healthcare Provider Details

I. General information

NPI: 1003341975
Provider Name (Legal Business Name): COREY J VAS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 N ALAMEDA BLVD STE 6
LAS CRUCES NM
88005-2172
US

IV. Provider business mailing address

741 N ALAMEDA BLVD STE 6
LAS CRUCES NM
88005-2172
US

V. Phone/Fax

Practice location:
  • Phone: 575-496-2616
  • Fax: 575-571-4483
Mailing address:
  • Phone: 575-496-2616
  • Fax: 575-571-4483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0844
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number0844
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number0844
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number0844
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number0844
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: