Provider Demographics
NPI:1871778365
Name:RIVERA, EDWIN IVAN (BA, MA)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:IVAN
Last Name:RIVERA
Suffix:
Gender:M
Credentials:BA, MA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:6501 VAN NUYS BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1425
Mailing Address - Country:US
Mailing Address - Phone:818-902-5315
Mailing Address - Fax:818-780-6562
Practice Address - Street 1:6501 VAN NUYS BLVD STE 103
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401
Practice Address - Country:US
Practice Address - Phone:818-902-5315
Practice Address - Fax:818-780-6562
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health