Healthcare Provider Details

I. General information

NPI: 1962977447
Provider Name (Legal Business Name): LUCELLY M. MEDEIROS RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 S ANGELINE ST, SEATTLE, WA 98118
SEATTLE WA
98118
US

IV. Provider business mailing address

2611 NE 125TH ST STE 145
SEATTLE WA
98125-4357
US

V. Phone/Fax

Practice location:
  • Phone: 206-461-4880
  • Fax:
Mailing address:
  • Phone: 206-437-5134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-15-09036
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61139749
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: