Provider Demographics
NPI:1821504911
Name:RIVAS-MENDOZA, MARTHA J
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:J
Last Name:RIVAS-MENDOZA
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 1:6071 LA PRADA ST APT 8
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-2063
Mailing Address - Country:US
Mailing Address - Phone:818-781-0360
Mailing Address - Fax:
Practice Address - Street 1:3130 BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91401
Practice Address - Country:US
Practice Address - Phone:818-781-0360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8742355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA874OtherSPEECH PATHOLOGY AND AUDIOLOGY AND HEARING AID DISPENSERS BOARD