=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407361785
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANA RIVERA RIVERA RODRIGUEZ PHD CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2017
-----------------------------------------------------
Last Update Date | 12/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 279 MAGNOLIA PARK TRL
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32773-7215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-262-9463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 279 MAGNOLIA PARK TRL
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32773-7215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-262-9463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA10845
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------