Provider Demographics
NPI:1528416625
Name:RIVERA, GUILLERMO
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 CLAIRE LN
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-3207
Mailing Address - Country:US
Mailing Address - Phone:407-989-3834
Mailing Address - Fax:
Practice Address - Street 1:130 CLAIRE LN
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-3207
Practice Address - Country:US
Practice Address - Phone:407-989-3834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101Y00000X
106S00000X
FLCBHCM102678171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician