Provider Demographics
NPI:1477087682
Name:RIVEROS, DIANA TAMARA (PTA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:TAMARA
Last Name:RIVEROS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7780 49TH ST N
Mailing Address - Street 2:# 154
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-3440
Mailing Address - Country:US
Mailing Address - Phone:727-369-6355
Mailing Address - Fax:727-362-4766
Practice Address - Street 1:4820 PARK BLVD N
Practice Address - Street 2:SUITE E
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-3534
Practice Address - Country:US
Practice Address - Phone:727-369-6355
Practice Address - Fax:727-362-4766
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27452225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant