Provider Demographics
NPI:1619236437
Name:RIVERA, JUDITH PATRICIA
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:PATRICIA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JUDITH
Other - Middle Name:PATRICIA
Other - Last Name:D'LEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1414 SANTA VICTORIA RD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-3658
Mailing Address - Country:US
Mailing Address - Phone:619-592-5151
Mailing Address - Fax:
Practice Address - Street 1:1414 SANTA VICTORIA RD UNIT 2
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-3658
Practice Address - Country:US
Practice Address - Phone:619-592-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTPMF615106H00000X
106H00000X, 390200000X
CA111379106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program