Provider Demographics
NPI:1962004614
Name:RIVERA GONZALEZ, JOSE MACARIO
Entity Type:Individual
Prefix:
First Name:JOSE MACARIO
Middle Name:
Last Name:RIVERA GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 TREAT BLVD STE C5
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94518-3631
Mailing Address - Country:US
Mailing Address - Phone:925-219-9009
Mailing Address - Fax:
Practice Address - Street 1:2975 TREAT BLVD STE C5
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94518-3631
Practice Address - Country:US
Practice Address - Phone:925-219-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103K00000X, 172V00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician