Provider Demographics
NPI:1548867484
Name:RIVERA, KENDAL LAUREN
Entity type:Individual
Prefix:
First Name:KENDAL
Middle Name:LAUREN
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENDAL
Other - Middle Name:LAUREN
Other - Last Name:HABEGGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:782 OXFORD WAY
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-3802
Mailing Address - Country:US
Mailing Address - Phone:707-373-9454
Mailing Address - Fax:
Practice Address - Street 1:1234 EMPIRE ST STE 1500
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5711
Practice Address - Country:US
Practice Address - Phone:707-373-9454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT112187101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health