Provider Demographics
NPI:1679180269
Name:RIVERA, KRISTIAN (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5948 TRAVERTINE LN APT 223
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-7089
Mailing Address - Country:US
Mailing Address - Phone:915-215-0517
Mailing Address - Fax:
Practice Address - Street 1:4801 S BUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-2373
Practice Address - Country:US
Practice Address - Phone:214-381-7700
Practice Address - Fax:972-707-0021
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1337573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist