MEDICARE: MRS. ELISABETH ANN RIVERA

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	:	1568694198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELISABETH ANN RIVERA

Provider Business Mailing Address
First Line	:	3447 N PAGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-2918
Country	:	US
Telephone Number	:	773-983-3241
Fax Number	:

Provider Business Practice Location Address
First Line	:	3447 N PAGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-2918
Country	:	US
Telephone Number	:	773-983-3241
Fax Number	:

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

Provider Enumeration Date	:	08/15/2009
Last Update Date	:	08/15/2009

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