Provider Demographics
NPI:1891465688
Name:LUCES-RIVA, TATIANA (PSYD)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:LUCES-RIVA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6252 ARALIA IVY LN
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-9536
Mailing Address - Country:US
Mailing Address - Phone:305-450-4328
Mailing Address - Fax:
Practice Address - Street 1:1573 W FAIRBANKS AVE STE 220
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4679
Practice Address - Country:US
Practice Address - Phone:407-303-7991
Practice Address - Fax:407-303-7803
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
FLPY11381103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist