Provider Demographics
NPI:1164113080
Name:MANUEL, MA ELAINE RIVERA
Entity Type:Individual
Prefix:
First Name:MA ELAINE
Middle Name:RIVERA
Last Name:MANUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MA ELAINE
Other - Middle Name:LISING
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6398 PEGASUS CT
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:91752-7613
Mailing Address - Country:US
Mailing Address - Phone:510-219-1921
Mailing Address - Fax:
Practice Address - Street 1:612 S MYRTLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3406
Practice Address - Country:US
Practice Address - Phone:626-775-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician