Healthcare Provider Details

I. General information

NPI: 1770494395
Provider Name (Legal Business Name): SANDRA LYNN RIVERA MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 W CARMEL DR
CARMEL IN
46032-7598
US

IV. Provider business mailing address

13813 MEADOW LAKE DR
FISHERS IN
46038-3092
US

V. Phone/Fax

Practice location:
  • Phone: 317-529-3428
  • Fax:
Mailing address:
  • Phone: 317-529-3428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT20900501
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: