Provider Demographics
NPI:1043963168
Name:RIVERA, VICTORIA (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4460 REDWOOD HWY STE 9
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1951
Mailing Address - Country:US
Mailing Address - Phone:415-360-4405
Mailing Address - Fax:
Practice Address - Street 1:18 COMMERCIAL BLVD STE 125
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-6120
Practice Address - Country:US
Practice Address - Phone:415-884-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT23233225X00000X, 225XM0800X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health