Provider Demographics
NPI:1275656548
Name:RIVERA, MARISA ELENA (MFT INTERN)
Entity Type:Individual
Prefix:MS
First Name:MARISA
Middle Name:ELENA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-2762
Mailing Address - Country:US
Mailing Address - Phone:909-983-2020
Mailing Address - Fax:909-983-6847
Practice Address - Street 1:855 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-2762
Practice Address - Country:US
Practice Address - Phone:909-983-2020
Practice Address - Fax:909-983-6847
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF46626106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist