Provider Demographics
NPI:1154167161
Name:RIVERA, MARCO ANTONIO
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
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 1:7160 NW 179TH ST APT 212
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5433
Mailing Address - Country:US
Mailing Address - Phone:629-800-4652
Mailing Address - Fax:
Practice Address - Street 1:7160 NW 179TH ST APT 212
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5433
Practice Address - Country:US
Practice Address - Phone:629-800-4652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician