Provider Demographics
NPI:1366015364
Name:RIVERA, EMILY GRACE (MS)
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:GRACE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4130
Mailing Address - Country:US
Mailing Address - Phone:407-215-0095
Mailing Address - Fax:
Practice Address - Street 1:925 OASIS PALM CIR APT 2211
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3324
Practice Address - Country:US
Practice Address - Phone:423-596-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health