Healthcare Provider Details

I. General information

NPI: 1619485612
Provider Name (Legal Business Name): ILYSSA RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 05/03/2023
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 LAUREN HILL CT
REISTERSTOWN MD
21136-6513
US

IV. Provider business mailing address

631 SIDELING CT
SYKESVILLE MD
21784-5805
US

V. Phone/Fax

Practice location:
  • Phone: 443-797-7706
  • Fax:
Mailing address:
  • Phone: 443-797-7706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA757
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: