Healthcare Provider Details

I. General information

NPI: 1629686712
Provider Name (Legal Business Name): GUADALUPE RIVAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 10/01/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 FOWLER LN
DIAMOND SPRINGS CA
95619-9781
US

IV. Provider business mailing address

PO BOX 1890
PLACERVILLE CA
95667-1890
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-3105
  • Fax:
Mailing address:
  • Phone: 530-409-8775
  • 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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: