Provider Demographics
NPI:1679109292
Name:RIVAS SANCHEZ, BERTA ELENA
Entity type:Individual
Prefix:
First Name:BERTA
Middle Name:ELENA
Last Name:RIVAS SANCHEZ
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 1:25127 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-3515
Mailing Address - Country:US
Mailing Address - Phone:760-590-2323
Mailing Address - Fax:
Practice Address - Street 1:16552 SUNHILL DR
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4518
Practice Address - Country:US
Practice Address - Phone:760-590-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-15
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA112091101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician