Provider Demographics
NPI:1700432325
Name:RIVERA, MAYRA MADELY (LMT)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:MADELY
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 CLAY ST APT 11
Mailing Address - Street 2:
Mailing Address - City:CENTRAL FALLS
Mailing Address - State:RI
Mailing Address - Zip Code:02863-3039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 EAST AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-6245
Practice Address - Country:US
Practice Address - Phone:401-640-0925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-11
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT02236225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist