Provider Demographics
NPI:1457672644
Name:RIVAS, SIRIS RAQUEL (MA CCC-SLP/LD)
Entity Type:Individual
Prefix:
First Name:SIRIS
Middle Name:RAQUEL
Last Name:RIVAS
Suffix:
Gender:F
Credentials:MA CCC-SLP/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 CARLISLE WAY
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-6601
Mailing Address - Country:US
Mailing Address - Phone:847-567-4978
Mailing Address - Fax:
Practice Address - Street 1:1851 W GREENLEAF AVE
Practice Address - Street 2:#1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-2303
Practice Address - Country:US
Practice Address - Phone:847-567-4978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009957235Z00000X
IL146009236235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist