Provider Demographics
NPI:1134701501
Name:RIVERA, TARA MARIE YSABEL
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE YSABEL
Last Name:RIVERA
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 1:1811 NAVARRE LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-5101
Mailing Address - Country:US
Mailing Address - Phone:702-856-9673
Mailing Address - Fax:
Practice Address - Street 1:9031 W LA MADRE WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-3536
Practice Address - Country:US
Practice Address - Phone:702-417-4753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator