Provider Demographics
NPI:1346648672
Name:RIVERA, LAURA (SLP)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 KALBORN RD
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-6735
Mailing Address - Country:US
Mailing Address - Phone:661-496-1659
Mailing Address - Fax:
Practice Address - Street 1:407 KALBORN RD
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-6735
Practice Address - Country:US
Practice Address - Phone:661-496-1659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7487235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA77-0562654OtherEIN