MEDICARE: TRICIA JANE RIVERA DOMALANTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2355S0801X	Speech-Language Assistant	9898	CA

General Provider Information

NPI Number	:	1619839388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRICIA JANE RIVERA DOMALANTA

Provider Business Mailing Address
First Line	:	923 N IVY LN
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92801-3431
Country	:	US
Telephone Number	:	714-234-5783
Fax Number	:

Provider Business Practice Location Address
First Line	:	5595 HUNTINGTON DR N
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90032-1324
Country	:	US
Telephone Number	:	323-576-2938
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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