Provider Demographics
NPI:1942990122
Name:RIVERA, LISANGELY (OTL)
Entity Type:Individual
Prefix:MRS
First Name:LISANGELY
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 194807
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-4807
Mailing Address - Country:US
Mailing Address - Phone:939-539-4739
Mailing Address - Fax:
Practice Address - Street 1:CARR. 110 INT. 111 KM. 12.8
Practice Address - Street 2:EDIF. MOCA PROFESSIONAL PLAZA OFIC. 203
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676
Practice Address - Country:US
Practice Address - Phone:939-539-4739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1264225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist