Provider Demographics
NPI:1104617307
Name:RIVERA, TASHA JUSTINE (PPS)
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:JUSTINE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12623 AVENUE 416
Mailing Address - Street 2:
Mailing Address - City:OROSI
Mailing Address - State:CA
Mailing Address - Zip Code:93647-2017
Mailing Address - Country:US
Mailing Address - Phone:559-528-4763
Mailing Address - Fax:559-528-9319
Practice Address - Street 1:12623 AVENUE 416
Practice Address - Street 2:
Practice Address - City:OROSI
Practice Address - State:CA
Practice Address - Zip Code:93647-2017
Practice Address - Country:US
Practice Address - Phone:559-528-4763
Practice Address - Fax:559-528-9319
Is Sole Proprietor?:No
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPP103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool