Provider Demographics
NPI:1033948864
Name:RIVERA, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:RIVERA
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 1:12340 SW 220TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-2802
Mailing Address - Country:US
Mailing Address - Phone:305-970-4220
Mailing Address - Fax:
Practice Address - Street 1:1350 SW 57TH AVE STE 313
Practice Address - Street 2:
Practice Address - City:WEST MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-5775
Practice Address - Country:US
Practice Address - Phone:786-216-7544
Practice Address - Fax:786-216-7543
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician