Provider Demographics
NPI:1093991291
Name:RAFOSO RIVAS, CARMEN (MS, SLP)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:RAFOSO RIVAS
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 NW 11TH ST
Mailing Address - Street 2:APT:1009
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-3105
Mailing Address - Country:US
Mailing Address - Phone:786-470-5453
Mailing Address - Fax:786-483-8466
Practice Address - Street 1:2500 NW 79TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33122-1003
Practice Address - Country:US
Practice Address - Phone:786-470-5453
Practice Address - Fax:786-483-8466
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA12969235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007137200Medicaid