=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033948864
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA RIVERA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2024
-----------------------------------------------------
Last Update Date | 07/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1350 SW 57TH AVE STE 313
-----------------------------------------------------
City | WEST MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33144-5775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-216-7544
-----------------------------------------------------
Fax | 786-216-7543
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12340 SW 220TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33170-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-970-4220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------