Provider Demographics
NPI:1649818949
Name:RIVERA, ASTRID
Entity type:Individual
Prefix:
First Name:ASTRID
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:PO BOX 71474
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-8574
Mailing Address - Country:US
Mailing Address - Phone:787-641-9133
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA 121, KM. 13.3
Practice Address - Street 2:
Practice Address - City:YAUCO
Practice Address - State:PR
Practice Address - Zip Code:00698
Practice Address - Country:US
Practice Address - Phone:787-641-9133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0080004658489OtherMOLINA HEATLTHCARE