Provider Demographics
NPI:1417435769
Name:RIVERA, MICHELLE (MS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:5263 VILLA ROSA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-7849
Mailing Address - Country:US
Mailing Address - Phone:407-724-5240
Mailing Address - Fax:321-250-7463
Practice Address - Street 1:5263 VILLA ROSA AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34771-7849
Practice Address - Country:US
Practice Address - Phone:407-724-5240
Practice Address - Fax:321-250-7463
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities