Provider Demographics
NPI:1073397683
Name:RIVERO DIAZ, PEDRO LUIS
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:LUIS
Last Name:RIVERO DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PEDRO
Other - Middle Name:
Other - Last Name:RIVERO DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5346 MOELLER AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-3267
Mailing Address - Country:US
Mailing Address - Phone:941-250-1265
Mailing Address - Fax:
Practice Address - Street 1:5346 MOELLER AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-3267
Practice Address - Country:US
Practice Address - Phone:941-250-1265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician