MEDICARE: MRS. SHERISA SHALENE BANTON 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	106H00000X	Marriage & Family Therapist	IMT4419	FL

General Provider Information

NPI Number	:	1912883414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHERISA SHALENE BANTON RIVERA

Provider Business Mailing Address
First Line	:	1501 BELVEDERE RD STE 500
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-1524
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1016 CLARE AVE STE 5
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-6219
Country	:	US
Telephone Number	:	561-703-2660
Fax Number	:

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

Provider Enumeration Date	:	08/12/2025
Last Update Date	:	08/12/2025

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