=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730456484
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERARDO RIVERA PMHNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2011
-----------------------------------------------------
Last Update Date | 11/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5156 BUFFALO SPEEDWAY
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-218-7825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 511 ARBOR CT
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77584-8135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-235-7247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 633985
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------