Provider Demographics
NPI:1174972525
Name:GACITA RIVERO, KENIA LUCIA
Entity type:Individual
Prefix:
First Name:KENIA
Middle Name:LUCIA
Last Name:GACITA RIVERO
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 1:642 W 37 ST.
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4771
Mailing Address - Country:US
Mailing Address - Phone:786-602-8839
Mailing Address - Fax:
Practice Address - Street 1:642 W 37 ST.
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4771
Practice Address - Country:US
Practice Address - Phone:786-602-8839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-15-07814106S00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018013300Medicaid