Provider Demographics
NPI:1720662042
Name:RIVERA, DORIS NYDIA (BS)
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:NYDIA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3873 KITTY HAWK AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-2721
Mailing Address - Country:US
Mailing Address - Phone:407-850-8689
Mailing Address - Fax:
Practice Address - Street 1:3800 W BROWARD BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1018
Practice Address - Country:US
Practice Address - Phone:813-443-4827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM101730171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator