Provider Demographics
NPI:1750307427
Name:RIVERA, ROBERT (PSYD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:PSYD
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 748519
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8519
Mailing Address - Country:US
Mailing Address - Phone:904-376-3800
Mailing Address - Fax:904-376-3998
Practice Address - Street 1:14540 OLD SAINT AUGUSTINE RD STE 2591
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7420
Practice Address - Country:US
Practice Address - Phone:904-376-3800
Practice Address - Fax:904-390-7405
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03845103T00000X
FLPY10893103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD436LG354Medicare PIN