Healthcare Provider Details

I. General information

NPI: 1750279089
Provider Name (Legal Business Name): RENEE JILL RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 ALAMEDA DE LAS PULGAS STE 200
SAN MATEO CA
94403-1293
US

IV. Provider business mailing address

PO BOX 880921
SAN FRANCISCO CA
94188-0921
US

V. Phone/Fax

Practice location:
  • Phone: 415-994-8704
  • Fax:
Mailing address:
  • Phone: 415-994-8704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number364595
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: