Provider Demographics
NPI:1225286834
Name:VIVEROS, EDGAR ALEJANDRO (MSW)
Entity Type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:ALEJANDRO
Last Name:VIVEROS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 POTRERO AVE
Mailing Address - Street 2:SUITE 7M-EDCM
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110
Mailing Address - Country:US
Mailing Address - Phone:415-206-5351
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:#7M
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110
Practice Address - Country:US
Practice Address - Phone:415-206-5540
Practice Address - Fax:415-206-8345
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 171M00000X, 104100000X
CAASW 29101101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760502298Medicaid
CAICAN828OtherLA COUNTY DMH