Provider Demographics
NPI:1700333994
Name:RIVERA, ISAMAR MILAGROS (MA CCC-SLP, TSSLD)
Entity Type:Individual
Prefix:MRS
First Name:ISAMAR
Middle Name:MILAGROS
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MA CCC-SLP, TSSLD
Other - Prefix:MS
Other - First Name:ISAMAR
Other - Middle Name:MILAGROS
Other - Last Name:LEDESMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:116 W 238TH ST APT 6G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-4221
Mailing Address - Country:US
Mailing Address - Phone:646-496-3596
Mailing Address - Fax:
Practice Address - Street 1:560 W 169TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3913
Practice Address - Country:US
Practice Address - Phone:212-927-0607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027279235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist