Provider Demographics
NPI:1164545562
Name:SOMERVILLE, COREY WAYNE (PT)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:WAYNE
Last Name:SOMERVILLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 S VALLEY VIEW BLVD
Mailing Address - Street 2:#3092
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4029
Mailing Address - Country:US
Mailing Address - Phone:570-371-7088
Mailing Address - Fax:
Practice Address - Street 1:4200 S VALLEY VIEW BLVD
Practice Address - Street 2:#3092
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4029
Practice Address - Country:US
Practice Address - Phone:570-371-7088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5401225100000X
PAPT018058225100000X
NV2262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist