Provider Demographics
NPI:1073383196
Name:RIVERA, TATYANA
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TATYANA
Other - Middle Name:
Other - Last Name:CALO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25209 CONESTOGA DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-9524
Mailing Address - Country:US
Mailing Address - Phone:813-297-2696
Mailing Address - Fax:
Practice Address - Street 1:18288 N US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-4400
Practice Address - Country:US
Practice Address - Phone:813-527-9638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-320937106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician