Provider Demographics
NPI:1083824650
Name:RIVERA, MYRNA GOMEZ (PSIC)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:GOMEZ
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PSIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 03 BOX 14749
Mailing Address - Street 2:
Mailing Address - City:AGUAS BUENAS
Mailing Address - State:PR
Mailing Address - Zip Code:00703
Mailing Address - Country:US
Mailing Address - Phone:787-312-8383
Mailing Address - Fax:
Practice Address - Street 1:AQUAMARINA #66 URB. VILLA BLANCA
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-743-1047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1281103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist