Provider Demographics
NPI:1689945586
Name:RIVERA, JONATHAN (PTA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30125 BARNABY LN
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-3702
Mailing Address - Country:US
Mailing Address - Phone:813-997-4118
Mailing Address - Fax:813-994-4118
Practice Address - Street 1:30125 BARNABY LN
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-3702
Practice Address - Country:US
Practice Address - Phone:813-997-4118
Practice Address - Fax:813-994-4118
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL260407362171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor