Provider Demographics
NPI:1770158875
Name:DE GRACIA RIVERA, SULEIKA MARIE (LPC)
Entity type:Individual
Prefix:
First Name:SULEIKA
Middle Name:MARIE
Last Name:DE GRACIA RIVERA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 S FORT HOOD ST STE 103B
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-1681
Mailing Address - Country:US
Mailing Address - Phone:254-239-1027
Mailing Address - Fax:
Practice Address - Street 1:1705 S FORT HOOD ST STE 103B
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-1681
Practice Address - Country:US
Practice Address - Phone:254-239-1027
Practice Address - Fax:254-200-2453
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81648101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81648Medicaid