Provider Demographics
NPI:1831640630
Name:RIVIECCIO, SUSAN (MFT INTERN)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:RIVIECCIO
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1581 BONANZA LN
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-7391
Mailing Address - Country:US
Mailing Address - Phone:916-412-5761
Mailing Address - Fax:
Practice Address - Street 1:1581 BONANZA LN
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-7391
Practice Address - Country:US
Practice Address - Phone:916-412-5761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82100106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist