Healthcare Provider Details

I. General information

NPI: 1386281558
Provider Name (Legal Business Name): PATRICIA MARIA DE LA RIVAHERRERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13037 NE BEL RED RD STE 102
BELLEVUE WA
98005-2618
US

IV. Provider business mailing address

1650 S TOPAZ WAY
MERIDIAN ID
83642-4474
US

V. Phone/Fax

Practice location:
  • Phone: 425-502-9945
  • Fax: 855-212-5682
Mailing address:
  • Phone: 208-810-2695
  • Fax: 208-898-3365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60945586
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLH60945586
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: