Provider Demographics
NPI:1235438086
Name:DETMER, KORI (CSW-INTERN)
Entity Type:Individual
Prefix:
First Name:KORI
Middle Name:
Last Name:DETMER
Suffix:
Gender:F
Credentials:CSW-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 E CHARLESTON BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-6681
Mailing Address - Country:US
Mailing Address - Phone:702-968-4000
Mailing Address - Fax:702-968-4040
Practice Address - Street 1:4000 E CHARLESTON BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-6681
Practice Address - Country:US
Practice Address - Phone:702-968-4000
Practice Address - Fax:702-968-4040
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVIC-7081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical