Provider Demographics
NPI:1811710031
Name:RIVERA, LUCETTE (MED,CCC-SLP)
Entity type:Individual
Prefix:
First Name:LUCETTE
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1637 ATHENS HWY
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1768
Mailing Address - Country:US
Mailing Address - Phone:770-995-9600
Mailing Address - Fax:678-383-4556
Practice Address - Street 1:1637 ATHENS HWY
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-1768
Practice Address - Country:US
Practice Address - Phone:770-995-9600
Practice Address - Fax:678-383-4556
Is Sole Proprietor?:No
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP013086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist