Provider Demographics
NPI:1992855191
Name:WONG-RIVADENEYRA, ANTONIO (LCSW)
Entity type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:
Last Name:WONG-RIVADENEYRA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 BROADWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2226
Mailing Address - Country:US
Mailing Address - Phone:707-645-2341
Mailing Address - Fax:707-645-2181
Practice Address - Street 1:1761 BROADWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2226
Practice Address - Country:US
Practice Address - Phone:707-645-2341
Practice Address - Fax:707-645-2181
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS10296101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health