Provider Demographics
NPI:1821757451
Name:RIVERA DE JESUS, WANDALYZ (MSW)
Entity Type:Individual
Prefix:
First Name:WANDALYZ
Middle Name:
Last Name:RIVERA DE JESUS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5496 PINE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRCHILD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:99011-2209
Mailing Address - Country:US
Mailing Address - Phone:787-943-0151
Mailing Address - Fax:
Practice Address - Street 1:5496 PINE ST
Practice Address - Street 2:
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011-2209
Practice Address - Country:US
Practice Address - Phone:787-943-0151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR143511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty