Provider Demographics
NPI:1295083095
Name:RIVAS, LAURA DIANE (MFT)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:DIANE
Last Name:RIVAS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23932 DORY DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-4237
Mailing Address - Country:US
Mailing Address - Phone:949-285-7136
Mailing Address - Fax:
Practice Address - Street 1:15615 ALTON PKWY STE 450
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3308
Practice Address - Country:US
Practice Address - Phone:949-791-7839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53934106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist