Provider Demographics
NPI:1205593837
Name:RIVERA, ANABELLE
Entity type:Individual
Prefix:
First Name:ANABELLE
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:CAMINO DE LA REINA
Mailing Address - Street 2:624 CARRETERA 8860 EDIF 6403
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ST. 833 KM. 12.4
Practice Address - Street 2:BO. LOS FRAILES
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00970
Practice Address - Country:US
Practice Address - Phone:797-731-7169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001972103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR001972Medicaid