Provider Demographics
NPI:1871868604
Name:CORDOVA, DOUGLAS
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:CORDOVA
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 1:6211 BLACK CINDER CT
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-7019
Mailing Address - Country:US
Mailing Address - Phone:775-412-3990
Mailing Address - Fax:
Practice Address - Street 1:1101 W MOANA LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4775
Practice Address - Country:US
Practice Address - Phone:775-337-2394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst