MEDICARE: MRS. SUELY G. RIVERA MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH18992	FL
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1174093892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUELY G. RIVERA MS

Provider Business Mailing Address
First Line	:	11885 FICTION AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32832-5120
Country	:	US
Telephone Number	:	321-465-2271
Fax Number	:

Provider Business Practice Location Address
First Line	:	7157 NARCOOSSEE RD # 1016
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32822-5533
Country	:	US
Telephone Number	:	321-878-3008
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/26/2018
Last Update Date	:	04/27/2021

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