Provider Demographics
NPI:1639719255
Name:RIVERA, SHEBOAN MARIE
Entity Type:Individual
Prefix:
First Name:SHEBOAN
Middle Name:MARIE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 NEEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0730
Mailing Address - Country:US
Mailing Address - Phone:209-569-0373
Mailing Address - Fax:
Practice Address - Street 1:1001 NEEDHAM ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0730
Practice Address - Country:US
Practice Address - Phone:209-569-0373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-11
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X, 106S00000X
CAAMFT141367106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician