Provider Demographics
NPI:1265894307
Name:YAMAMURA, COREY
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:YAMAMURA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-0031
Mailing Address - Country:US
Mailing Address - Phone:716-775-7271
Mailing Address - Fax:
Practice Address - Street 1:BASELINE RD.
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072
Practice Address - Country:US
Practice Address - Phone:716-775-7271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 171M00000X, 172V00000X, 174H00000X, 373H00000X, 101YM0800X, 174H00000X, 373H00000X, 101Y00000X
NYNOTNEEDED405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No174H00000XOther Service ProvidersHealth Educator
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No405300000XOther Service ProvidersPrevention Professional