Provider Demographics
NPI:1053678235
Name:MALITZ, CORIE
Entity Type:Individual
Prefix:
First Name:CORIE
Middle Name:
Last Name:MALITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7615 LUMBERJACK AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-5362
Mailing Address - Country:US
Mailing Address - Phone:702-492-0637
Mailing Address - Fax:
Practice Address - Street 1:1120 N TOWN CENTER DR STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6302
Practice Address - Country:US
Practice Address - Phone:866-960-7691
Practice Address - Fax:866-960-7692
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1479225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist