Provider Demographics
NPI:1316587298
Name:RIVERA ROSA, KAISY JOAN
Entity Type:Individual
Prefix:
First Name:KAISY
Middle Name:JOAN
Last Name:RIVERA ROSA
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 1:23941 SW 117TH CT
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-3003
Mailing Address - Country:US
Mailing Address - Phone:786-970-1378
Mailing Address - Fax:
Practice Address - Street 1:23941 SW 117TH CT
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-3003
Practice Address - Country:US
Practice Address - Phone:786-970-1378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst