Healthcare Provider Details

I. General information

NPI: 1346011855
Provider Name (Legal Business Name): SARAH ROCHELLE SALAZAR GERVACIO RIVERA APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SARAH GERVACIO

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 SHADOWRIDGE DR
VISTA CA
92083-7986
US

IV. Provider business mailing address

PO BOX 45061
SAN DIEGO CA
92145-0061
US

V. Phone/Fax

Practice location:
  • Phone: 833-579-4848
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15077
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: