Provider Demographics
NPI:1447741194
Name:RIVERO QUINTANAL, MAIDENIS
Entity Type:Individual
Prefix:
First Name:MAIDENIS
Middle Name:
Last Name:RIVERO QUINTANAL
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 1:25200 SW 207TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33031-1549
Mailing Address - Country:US
Mailing Address - Phone:702-517-6506
Mailing Address - Fax:
Practice Address - Street 1:5422 BECK ST
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-6503
Practice Address - Country:US
Practice Address - Phone:702-517-6506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-19-10074106E00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023525200Medicaid