Provider Demographics
NPI:1558975268
Name:RIVERA, CALYPSO MARES (MC54976)
Entity Type:Individual
Prefix:
First Name:CALYPSO
Middle Name:MARES
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MC54976
Other - Prefix:
Other - First Name:CALYPSO
Other - Middle Name:MARES
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MC54976
Mailing Address - Street 1:5424 S STEELE ST APT 27
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7005
Mailing Address - Country:US
Mailing Address - Phone:253-314-2766
Mailing Address - Fax:
Practice Address - Street 1:5424 S STEELE ST APT 27
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7005
Practice Address - Country:US
Practice Address - Phone:253-314-2766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMC54976Medicaid