Provider Demographics
NPI:1588194716
Name:SANTIAGO RIVERA, MARIELA (SLP)
Entity Type:Individual
Prefix:
First Name:MARIELA
Middle Name:
Last Name:SANTIAGO RIVERA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15701 STATE ROAD 50 STE 202
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-9203
Mailing Address - Country:US
Mailing Address - Phone:407-347-7589
Mailing Address - Fax:
Practice Address - Street 1:15701 STATE ROAD 50 STE 202
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-9203
Practice Address - Country:US
Practice Address - Phone:407-347-7589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4044235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105193600Medicaid