Provider Demographics
NPI:1770107906
Name:RIVAS, STEPHANIE LIZETT (BA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LIZETT
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 1:1390 S DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-5270
Mailing Address - Country:US
Mailing Address - Phone:405-455-5312
Mailing Address - Fax:
Practice Address - Street 1:1390 S DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5270
Practice Address - Country:US
Practice Address - Phone:405-455-5312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator