Healthcare Provider Details

I. General information

NPI: 1508226101
Provider Name (Legal Business Name): AGUSTIN RIVERA M.D; MC; CLERGY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E LANCASTER RD
ORLANDO FL
32809-6689
US

IV. Provider business mailing address

17906 WOODCREST WAY
CLERMONT FL
34714-5906
US

V. Phone/Fax

Practice location:
  • Phone: 863-582-9899
  • Fax:
Mailing address:
  • Phone: 863-420-9899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPHM 1453
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number1702-002
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number557
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: