Provider Demographics
NPI:1962977447
Name:MEDEIROS RIVERA, LUCELLY M
Entity type:Individual
Prefix:
First Name:LUCELLY
Middle Name:M
Last Name:MEDEIROS RIVERA
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 1:2611 NE 125TH ST STE 145
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-4357
Mailing Address - Country:US
Mailing Address - Phone:206-437-5134
Mailing Address - Fax:
Practice Address - Street 1:3808 S ANGELINE ST, SEATTLE, WA 98118
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118
Practice Address - Country:US
Practice Address - Phone:206-461-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101Y00000X, 101YM0800X
WARBT-15-09036106S00000X
WACG61139749101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician