Provider Demographics
NPI:1568425304
Name:RIVAS-VAZQUEZ, RAFAEL A (PSYD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:A
Last Name:RIVAS-VAZQUEZ
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9960 NW 116TH WAY
Mailing Address - Street 2:SUITE 13
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33178-1167
Mailing Address - Country:US
Mailing Address - Phone:786-924-1311
Mailing Address - Fax:786-924-1313
Practice Address - Street 1:8940 N KENDALL DR
Practice Address - Street 2:SUITE 802E
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2148
Practice Address - Country:US
Practice Address - Phone:305-595-4041
Practice Address - Fax:305-595-6638
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4519103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist