Provider Demographics
NPI:1255802617
Name:RIVERA, KELLY LYNN
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:PALAZZOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:523 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-4354
Mailing Address - Country:US
Mailing Address - Phone:352-201-0689
Mailing Address - Fax:
Practice Address - Street 1:523 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-4354
Practice Address - Country:US
Practice Address - Phone:352-201-0689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician