Healthcare Provider Details

I. General information

NPI: 1568534899
Provider Name (Legal Business Name): GEORGETTE RIERA RODER ITDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 NW 12TH AVE STE 206
MIAMI FL
33136-1005
US

IV. Provider business mailing address

800 N.E. 195 STREET 613
MIAMI FL
33179-3439
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-6660
  • Fax:
Mailing address:
  • Phone: 786-246-0268
  • Fax: 305-653-7189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: