Provider Demographics
NPI:1700241395
Name:RIVERA, GERARDO (912)
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:912
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COND. NEW SAN JUAN
Mailing Address - Street 2:APT 318 AVE ISLA VERDE
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979
Mailing Address - Country:US
Mailing Address - Phone:787-698-1217
Mailing Address - Fax:
Practice Address - Street 1:CARR 31 KM 22.4
Practice Address - Street 2:BO. CEIBA NORTE
Practice Address - City:JUNCOS
Practice Address - State:PR
Practice Address - Zip Code:00777
Practice Address - Country:US
Practice Address - Phone:787-679-6569
Practice Address - Fax:939-336-7250
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR912235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist