Healthcare Provider Details

I. General information

NPI: 1851266993
Provider Name (Legal Business Name): MIRIAM SUGEI RIVERA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2025
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 BABCOCK RD STE 19
SAN ANTONIO TX
78229-4437
US

IV. Provider business mailing address

250 W LANCASTER AVE APT 1523
FORT WORTH TX
76102-6361
US

V. Phone/Fax

Practice location:
  • Phone: 210-761-9001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1212542
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: