Provider Demographics
NPI:1619702578
Name:GUTIERREZ RIVERO, YANDRY
Entity type:Individual
Prefix:
First Name:YANDRY
Middle Name:
Last Name:GUTIERREZ RIVERO
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 1:441 BROWARD AVE
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-2001
Mailing Address - Country:US
Mailing Address - Phone:561-654-3933
Mailing Address - Fax:
Practice Address - Street 1:4793 N CONGRESS AVE STE 203-204
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-7937
Practice Address - Country:US
Practice Address - Phone:561-429-3863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1149377106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician