Provider Demographics
NPI:1851328397
Name:(OTT) RIVERA, MICHELLE PATRICE (MS, RD, CDE, LD)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:PATRICE
Last Name:(OTT) RIVERA
Suffix:
Gender:F
Credentials:MS, RD, CDE, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6419 ALLENTOWN DRIVE
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-3669
Mailing Address - Country:US
Mailing Address - Phone:281-682-5967
Mailing Address - Fax:
Practice Address - Street 1:6419 ALLENTOWN DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77389-3669
Practice Address - Country:US
Practice Address - Phone:281-682-5967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06278133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX61046Medicare ID - Type UnspecifiedGROUP NUMBER