Provider Demographics
NPI:1508226101
Name:RIVERA, AGUSTIN (MD; MC; CLERGY)
Entity Type:Individual
Prefix:DR
First Name:AGUSTIN
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD; MC; CLERGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17906 WOODCREST WAY
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-5906
Mailing Address - Country:US
Mailing Address - Phone:863-420-9899
Mailing Address - Fax:
Practice Address - Street 1:115 E LANCASTER RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-6689
Practice Address - Country:US
Practice Address - Phone:863-582-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1702-002101YP1600X
PR557106H00000X
FLPHM 1453101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL805036272OtherFUNCTIONAL ASSESSMENT RATING SCALE
PR1001A-1005OtherTRAUMATOLOGY
FL802042738OtherCHILDREN'S FUNCTIONAL ASSESMENT RATING SCALE
CACEP 15893OtherSEXUAL ASSAULT FORENSIC EXAMINER TRAINING
PRMFT 557OtherMARRIAGE AND FAMILY COUNSELING
PRXXXXOtherMEDICAL DOCTOR
FLCOURSE 20-32231OtherQUALIFIED SUPERVISOR TRAINING
FLP852 NAADAOtherPROFESSIONAL CERTIFICATE IN COUNSELING ADDICTIVE DISORDERS AND MENTAL HEALTH
FLPHM 1453OtherMENTAL HEALTH COUNSELOR
FL2543OtherDIPLOMATE AMERICAN BOARD OF SEXOLOGY