Provider Demographics
NPI:1366110926
Name:RIVERA, GUSTAVO ANDRES
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ANDRES
Last Name:RIVERA
Suffix:
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 1:724 CREST PINES DR APT 511
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7193
Mailing Address - Country:US
Mailing Address - Phone:787-502-3086
Mailing Address - Fax:
Practice Address - Street 1:12702 SCIENCE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-3016
Practice Address - Country:US
Practice Address - Phone:407-574-2073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician