Healthcare Provider Details

I. General information

NPI: 1154972347
Provider Name (Legal Business Name): PRISCILLA ANGELINA RIVERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 S LEWIS RD
CAMARILLO CA
93012-8520
US

IV. Provider business mailing address

165 MAIN ST
FILLMORE CA
93015-2116
US

V. Phone/Fax

Practice location:
  • Phone: 805-366-4040
  • Fax:
Mailing address:
  • Phone: 805-248-8024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: