Provider Demographics
NPI:1669846549
Name:RIVERA, REVAE (ATC, LAT)
Entity Type:Individual
Prefix:MS
First Name:REVAE
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 630
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78839-0630
Mailing Address - Country:US
Mailing Address - Phone:903-504-7140
Mailing Address - Fax:
Practice Address - Street 1:805 E CROCKETT ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78839-2711
Practice Address - Country:US
Practice Address - Phone:830-374-2341
Practice Address - Fax:830-374-8012
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT63402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer