MEDICARE: MS. MARIELY RIVERA-ROHENA ITDS

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	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1194956805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARIELY RIVERA-ROHENA ITDS

Provider Business Mailing Address
First Line	:	4224 N WILDER RD
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33565-2330
Country	:	US
Telephone Number	:	863-412-6929
Fax Number	:	863-299-9239

Provider Business Practice Location Address
First Line	:	4224 N WILDER RD
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33565-2330
Country	:	US
Telephone Number	:	863-412-6929
Fax Number	:	863-299-9239

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

Provider Enumeration Date	:	07/29/2009
Last Update Date	:	07/29/2009

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