Provider Demographics
NPI:1104452382
Name:RIVERA, GENESIES SARAI
Entity type:Individual
Prefix:
First Name:GENESIES
Middle Name:SARAI
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 E LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-5415
Mailing Address - Country:US
Mailing Address - Phone:407-202-8292
Mailing Address - Fax:
Practice Address - Street 1:1110 E LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5415
Practice Address - Country:US
Practice Address - Phone:407-202-8292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker