Provider Demographics
NPI:1982198628
Name:RIVERA, KENNETH ELIJAH JR
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ELIJAH
Last Name:RIVERA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 PARK HILL DR
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33417-5700
Mailing Address - Country:US
Mailing Address - Phone:561-502-5310
Mailing Address - Fax:
Practice Address - Street 1:9150 SW 21ST DR
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7925
Practice Address - Country:US
Practice Address - Phone:772-222-5560
Practice Address - Fax:844-652-8088
Is Sole Proprietor?:No
Enumeration Date:2018-06-17
Last Update Date:2018-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician