Healthcare Provider Details

I. General information

NPI: 1073813077
Provider Name (Legal Business Name): CORNELIUS HEALY S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 GALLETTI WAY
SPARKS NV
89431-5564
US

IV. Provider business mailing address

480 GALLETTI WAY
SPARKS NV
89431-5564
US

V. Phone/Fax

Practice location:
  • Phone: 775-688-2001
  • Fax: 775-688-2004
Mailing address:
  • Phone: 775-688-2001
  • Fax: 775-688-2004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number00993-S
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: