Provider Demographics
NPI:1285902254
Name:RIVERA, GINNETTE M (PSYD)
Entity type:Individual
Prefix:DR
First Name:GINNETTE
Middle Name:M
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16635 SPACEMORE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-6383
Mailing Address - Country:US
Mailing Address - Phone:787-220-8355
Mailing Address - Fax:
Practice Address - Street 1:151 CALLE TANCA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00901-1412
Practice Address - Country:US
Practice Address - Phone:787-725-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3934103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical