Provider Demographics
NPI:1770305120
Name:RIVERS, FREDAIZHA ALEXIS
Entity type:Individual
Prefix:
First Name:FREDAIZHA
Middle Name:ALEXIS
Last Name:RIVERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 ASHLEY AVE APT A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-3081
Mailing Address - Country:US
Mailing Address - Phone:346-652-4712
Mailing Address - Fax:
Practice Address - Street 1:350 FAIRWAY DR STE 101
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-1834
Practice Address - Country:US
Practice Address - Phone:754-336-3892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC104403768106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician