Provider Demographics
NPI:1417556861
Name:RIVAS PEREZ, MAYDEL
Entity Type:Individual
Prefix:
First Name:MAYDEL
Middle Name:
Last Name:RIVAS PEREZ
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 1:20225 SW 106TH CT
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-1327
Mailing Address - Country:US
Mailing Address - Phone:305-484-1095
Mailing Address - Fax:
Practice Address - Street 1:20225 SW 106TH CT
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33189-1327
Practice Address - Country:US
Practice Address - Phone:305-484-1095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-17
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB566108106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician