Basic Information
| Provider Information | |||||||||
| NPI: | 1962977447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDEIROS RIVERA | ||||||||
| FirstName: | LUCELLY | ||||||||
| MiddleName: | M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2611 NE 125TH ST STE 145 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981254357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064375134 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3808 S ANGELINE ST, SEATTLE, WA 98118 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064614880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2018 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | WA | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106S00000X | RBT-15-09036 | WA | N | 101Y00000X | CG61139749 | WA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.