Healthcare Provider Details

I. General information

NPI: 1669002192
Provider Name (Legal Business Name): PRISCILLA RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6840 INDIANA AVE STE 275
RIVERSIDE CA
92506-4279
US

IV. Provider business mailing address

PO BOX 3551
RIVERSIDE CA
92519-3551
US

V. Phone/Fax

Practice location:
  • Phone: 951-778-0230
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7230
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: