MEDICARE: CORY VANDERHILL

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	103TA0400X	Addiction (Substance Use Disorder) Psychologist
2	172V00000X	Community Health Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1500151870	OTHER	NV	HEALTH PLAN OF NEVADA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396286761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORY VANDERHILL

Provider Business Mailing Address
First Line	:	2150 N TENAYA WAY
Second Line	:	APT# 1212
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0402
Country	:	US
Telephone Number	:	702-412-5566
Fax Number	:

Provider Business Practice Location Address
First Line	:	2150 N TENAYA WAY
Second Line	:	1212
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0402
Country	:	US
Telephone Number	:	702-412-5566
Fax Number	:

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

Provider Enumeration Date	:	03/17/2017
Last Update Date	:	03/17/2017

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Directions to “ CORY VANDERHILL ” Practice Location

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