Provider Demographics
NPI:1184379513
Name:RIVERA, JAVIER ANTONIO (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JAVIER
Middle Name:ANTONIO
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 W LAUREEN ST
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-9503
Mailing Address - Country:US
Mailing Address - Phone:727-437-2892
Mailing Address - Fax:
Practice Address - Street 1:2790 W LAUREEN ST
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-9503
Practice Address - Country:US
Practice Address - Phone:727-437-2892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP15378235Z00000X
FLSA21164235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117181500Medicaid