=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215077763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICCARDO B RIVAS PH.D.,PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3435 10TH ST N SUITE 303
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34103-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-434-2150
-----------------------------------------------------
Fax | 239-649-5051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3435 10TH ST N SUITE 303
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34103-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-434-2150
-----------------------------------------------------
Fax | 239-649-5051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICCARDO B RIVAS
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 239-434-2150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY 3708
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------