Provider Demographics
NPI:1770707267
Name:RIVICH, TYSHA L
Entity type:Individual
Prefix:
First Name:TYSHA
Middle Name:L
Last Name:RIVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8091 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-7068
Mailing Address - Country:US
Mailing Address - Phone:219-942-5590
Mailing Address - Fax:815-301-8797
Practice Address - Street 1:8200 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6227
Practice Address - Country:US
Practice Address - Phone:219-791-1400
Practice Address - Fax:219-791-1422
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IN1-12-12460103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health