=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154816551
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA LIZBETH RODRIGUEZ RIVERA MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2018
-----------------------------------------------------
Last Update Date | 09/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17340 YOLO AVE
-----------------------------------------------------
City | ESPARTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95627-2265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-787-4110
-----------------------------------------------------
Fax | 530-787-4104
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1501 15TH ST APT 1
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95814-6019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-821-4368
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 141395
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------