Provider Demographics
NPI:1083348643
Name:RIVERO GONZALEZ, DIANELIS
Entity Type:Individual
Prefix:
First Name:DIANELIS
Middle Name:
Last Name:RIVERO GONZALEZ
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 1:4550 W 16TH AVE APT 4550W16
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2886
Mailing Address - Country:US
Mailing Address - Phone:786-817-0532
Mailing Address - Fax:
Practice Address - Street 1:4550 W 16TH AVE APT 4550W16
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2886
Practice Address - Country:US
Practice Address - Phone:786-817-0532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09261993Medicaid