Provider Demographics
NPI:1407143357
Name:RIVAS, EDGAR R
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:R
Last Name:RIVAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4085 N RANCHO DR STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3467
Mailing Address - Country:US
Mailing Address - Phone:562-572-6849
Mailing Address - Fax:800-783-6931
Practice Address - Street 1:4085 N RANCHO DR STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3467
Practice Address - Country:US
Practice Address - Phone:562-572-6849
Practice Address - Fax:800-783-6931
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst