Provider Demographics
NPI:1417314832
Name:CORTEZ, VIVIENNE
Entity Type:Individual
Prefix:
First Name:VIVIENNE
Middle Name:
Last Name:CORTEZ
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 1:260 E PARR BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89512-1002
Mailing Address - Country:US
Mailing Address - Phone:775-276-4149
Mailing Address - Fax:
Practice Address - Street 1:260 E PARR BLVD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-1002
Practice Address - Country:US
Practice Address - Phone:775-276-4149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-16
Last Update Date:2016-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV00001918805Medicaid