Provider Demographics
NPI:1093450405
Name:RIVINIUS, KELLY CAULEY
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:CAULEY
Last Name:RIVINIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 CALIFORNIA ST STE E
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4247
Mailing Address - Country:US
Mailing Address - Phone:909-754-0865
Mailing Address - Fax:
Practice Address - Street 1:11201 CALIFORNIA ST STE E
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4247
Practice Address - Country:US
Practice Address - Phone:909-754-0865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28377103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical