=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801505839
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAOLA ALEJANDRA RIVAS MS., LCDC-I
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2022
-----------------------------------------------------
Last Update Date | 11/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4405 PADRE BLVD
-----------------------------------------------------
City | SOUTH PADRE ISLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78597-7324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-299-4767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4405 PADRE BLVD
-----------------------------------------------------
City | SOUTH PADRE ISLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78597-7324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-299-4767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 41437
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------