Provider Demographics
NPI:1396286761
Name:VANDERHILL, CORY
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:VANDERHILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 N TENAYA WAY
Mailing Address - Street 2:APT# 1212
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0402
Mailing Address - Country:US
Mailing Address - Phone:702-412-5566
Mailing Address - Fax:
Practice Address - Street 1:2150 N TENAYA WAY
Practice Address - Street 2:1212
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0402
Practice Address - Country:US
Practice Address - Phone:702-412-5566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1500151870OtherHEALTH PLAN OF NEVADA
NV0000143106Medicaid