Provider Demographics
NPI:1528584232
Name:RIVAS, INDHIRA M
Entity Type:Individual
Prefix:
First Name:INDHIRA
Middle Name:M
Last Name:RIVAS
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:ST. 18 Q53
Mailing Address - Street 2:VILLAS DE LOIZA
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729-4258
Mailing Address - Country:US
Mailing Address - Phone:787-550-3369
Mailing Address - Fax:
Practice Address - Street 1:1551 CALLE VICTORIA SANTURCE
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00912
Practice Address - Country:US
Practice Address - Phone:787-722-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5542103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty