Provider Demographics
NPI:1104643030
Name:RIVERA WILLIAMS, DOMINIQUE JORDAN (DPT)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:JORDAN
Last Name:RIVERA WILLIAMS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5840 CORPORATE WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2040
Mailing Address - Country:US
Mailing Address - Phone:561-432-0111
Mailing Address - Fax:561-432-1075
Practice Address - Street 1:1903 S CONGRESS AVE STE 100
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-6553
Practice Address - Country:US
Practice Address - Phone:561-432-0111
Practice Address - Fax:561-432-1075
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT42299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist