Provider Demographics
NPI:1093174443
Name:RIVERA, BLANCA
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:
Last Name:RIVERA
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 1:11111 SW 10TH ST
Mailing Address - Street 2:9-2
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-5509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11111 SW 10TH ST
Practice Address - Street 2:9-2
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-5509
Practice Address - Country:US
Practice Address - Phone:786-213-0227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-14
Last Update Date:2016-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral