Healthcare Provider Details

I. General information

NPI: 1104617307
Provider Name (Legal Business Name): TASHA JUSTINE RIVERA PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12623 AVENUE 416
OROSI CA
93647-2017
US

IV. Provider business mailing address

12623 AVENUE 416
OROSI CA
93647-2017
US

V. Phone/Fax

Practice location:
  • Phone: 559-528-4763
  • Fax: 559-528-9319
Mailing address:
  • Phone: 559-528-4763
  • Fax: 559-528-9319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberPP
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: