Provider Demographics
NPI:1114210796
Name:RIVERA AVILES, LISANDRA (OT)
Entity Type:Individual
Prefix:
First Name:LISANDRA
Middle Name:
Last Name:RIVERA AVILES
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00694-0468
Mailing Address - Country:US
Mailing Address - Phone:787-596-3497
Mailing Address - Fax:787-270-5292
Practice Address - Street 1:CARRETERA 693 BO. BRENAS
Practice Address - Street 2:EDIF. ANCHOR HEART SUITE 6
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692
Practice Address - Country:US
Practice Address - Phone:787-270-2686
Practice Address - Fax:787-270-5292
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR966225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist