Provider Demographics
NPI:1124806781
Name:RIVERA, ANGEL GABRIEL
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:GABRIEL
Last Name:RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 STATION SQ APT 417
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-1643
Mailing Address - Country:US
Mailing Address - Phone:689-241-1028
Mailing Address - Fax:
Practice Address - Street 1:2901 E IRLO BRONSON MEMORIAL HWY STE D
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5600
Practice Address - Country:US
Practice Address - Phone:407-483-4750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-315279106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician