Basic Information
| Provider Information | |||||||||
| NPI: | 1821504911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVAS-MENDOZA | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6071 LA PRADA ST APT 8 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900422063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187810360 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3130 BURBANK BLVD | ||||||||
| Address2: | |||||||||
| City: | SHERMAN OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187810360 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | 874 | CA | Y | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
ID Information
| ID | Type | State | Issuer | Description | 874 | 01 | CA | SPEECH PATHOLOGY AND AUDIOLOGY AND HEARING AID DISPENSERS BOARD | OTHER |