Provider Demographics
NPI:1497386742
Name:RIVERA, MEKAYLA DANIELLE
Entity Type:Individual
Prefix:
First Name:MEKAYLA
Middle Name:DANIELLE
Last Name:RIVERA
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 1:2121 WINTER MOSS LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-7784
Mailing Address - Country:US
Mailing Address - Phone:910-583-8036
Mailing Address - Fax:
Practice Address - Street 1:500 MILITARY CUTOFF RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-9737
Practice Address - Country:US
Practice Address - Phone:910-392-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-21-56568103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst