Provider Demographics
NPI:1164061040
Name:RIVERA, IAN HUGH ADON (LCSW, MCAP)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:HUGH ADON
Last Name:RIVERA
Suffix:
Gender:M
Credentials:LCSW, MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12745 LEMON PEPPER DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-7585
Mailing Address - Country:US
Mailing Address - Phone:414-312-1010
Mailing Address - Fax:
Practice Address - Street 1:1047 E BRANDON BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5515
Practice Address - Country:US
Practice Address - Phone:414-312-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-24
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW170931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical