Provider Demographics
NPI:1982371159
Name:RIVAS, SELENA JAZMIN (RBT)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:JAZMIN
Last Name:RIVAS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 N BROOKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2520
Mailing Address - Country:US
Mailing Address - Phone:262-573-1046
Mailing Address - Fax:
Practice Address - Street 1:10930 W POTTER RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3450
Practice Address - Country:US
Practice Address - Phone:262-200-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIRBT-21-151119106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIRBT-21-151119OtherRBT