Provider Demographics
NPI:1639382815
Name:RIVERA, BEVERLY CAROL (PHD)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:CAROL
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18917 NORDHOFF ST STE 18
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-4823
Mailing Address - Country:US
Mailing Address - Phone:818-397-1260
Mailing Address - Fax:818-341-3806
Practice Address - Street 1:18917 NORDHOFF ST STE 18
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324
Practice Address - Country:US
Practice Address - Phone:818-397-1260
Practice Address - Fax:818-341-3806
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2018-06-05
Deactivation Date:2012-04-10
Deactivation Code:
Reactivation Date:2012-04-24
Provider Licenses
StateLicense IDTaxonomies
CAPSY20466103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABV640AMedicare PIN