Healthcare Provider Details

I. General information

NPI: 1891602199
Provider Name (Legal Business Name): MARCELINO ANTONIO RIVAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 W OSBORN RD
PHOENIX AZ
85013-3695
US

IV. Provider business mailing address

3507 W ELM ST
PHOENIX AZ
85019-3001
US

V. Phone/Fax

Practice location:
  • Phone: 602-707-2000
  • Fax:
Mailing address:
  • Phone: 480-881-1868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA13617
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: