Healthcare Provider Details

I. General information

NPI: 1184023053
Provider Name (Legal Business Name): SEZCOV I RIVERA SANTANA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2014
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 5071 BOX MDG
APO AP
96328-5071
US

IV. Provider business mailing address

UNIT 5071 BOX MDG
APO AP
96328-5071
US

V. Phone/Fax

Practice location:
  • Phone: 315-225-3566
  • Fax:
Mailing address:
  • Phone: 315-225-3566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5557
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35778
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: