Provider Demographics
NPI:1780006155
Name:RIVERA, THAIZ
Entity Type:Individual
Prefix:
First Name:THAIZ
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 4 BOX 13482
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-9568
Mailing Address - Country:US
Mailing Address - Phone:787-517-9298
Mailing Address - Fax:
Practice Address - Street 1:HC 4 BOX 13482
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683-9568
Practice Address - Country:US
Practice Address - Phone:787-517-9298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-20
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5552103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical