Healthcare Provider Details

I. General information

NPI: 1932481512
Provider Name (Legal Business Name): LUNA MICHELLE RIVERA MA, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5165 ADANSON ST
ORLANDO FL
32804-1331
US

IV. Provider business mailing address

5165 ADANSON ST
ORLANDO FL
32804-1331
US

V. Phone/Fax

Practice location:
  • Phone: 407-408-7402
  • Fax: 407-627-0303
Mailing address:
  • Phone: 407-408-7402
  • Fax: 407-627-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH 8672
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-15-17923
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: