Provider Demographics
NPI:1538790365
Name:RIVAS, PRISCILLA SAMANTHA (BA)
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:SAMANTHA
Last Name:RIVAS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9845 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-2758
Mailing Address - Country:US
Mailing Address - Phone:708-786-2049
Mailing Address - Fax:
Practice Address - Street 1:9845 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-2758
Practice Address - Country:US
Practice Address - Phone:708-786-2049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty