Provider Demographics
NPI:1518425339
Name:RIVERA, MIRIAM N (PTA)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:N
Last Name:RIVERA
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 1:1546 ROBERTS AVE
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:IN
Mailing Address - Zip Code:46394-1122
Mailing Address - Country:US
Mailing Address - Phone:219-688-7636
Mailing Address - Fax:
Practice Address - Street 1:1546 ROBERTS AVE
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:IN
Practice Address - Zip Code:46394-1122
Practice Address - Country:US
Practice Address - Phone:219-688-7636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.006353225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant