Provider Demographics
NPI:1033452610
Name:DISON DE RIVAS, TAMRA ANN
Entity type:Individual
Prefix:
First Name:TAMRA
Middle Name:ANN
Last Name:DISON DE RIVAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMRA
Other - Middle Name:ANN
Other - Last Name:DISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1255 KENDALL RD
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-8750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1255 KENDALL RD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-8750
Practice Address - Country:US
Practice Address - Phone:805-781-3535
Practice Address - Fax:805-503-6499
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator