Provider Demographics
NPI:1093233868
Name:RIVERA, SARAH S (PSS)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:S
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PSS
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:S
Other - Last Name:VELASQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSS
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:971-386-2278
Mailing Address - Fax:503-224-4494
Practice Address - Street 1:12360 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1042
Practice Address - Country:US
Practice Address - Phone:971-279-4800
Practice Address - Fax:971-279-2051
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000002250175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500734496Medicaid