Healthcare Provider Details

I. General information

NPI: 1639719255
Provider Name (Legal Business Name): SHEBOAN MARIE RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2020
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 NEEDHAM ST
MODESTO CA
95354-0730
US

IV. Provider business mailing address

1001 NEEDHAM ST
MODESTO CA
95354-0730
US

V. Phone/Fax

Practice location:
  • Phone: 209-569-0373
  • Fax:
Mailing address:
  • Phone: 209-569-0373
  • 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 TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT141367
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: