Provider Demographics
NPI:1740970391
Name:RIVAS, CRYSTAL D (COTA/L)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:D
Last Name:RIVAS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19280 YANAN RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-4759
Mailing Address - Country:US
Mailing Address - Phone:909-235-3380
Mailing Address - Fax:
Practice Address - Street 1:17800 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1221
Practice Address - Country:US
Practice Address - Phone:760-955-3674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3011224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant