Provider Demographics
NPI:1336935683
Name:SANTIAGO RIVERA, KETZYLIE M
Entity type:Individual
Prefix:
First Name:KETZYLIE
Middle Name:M
Last Name:SANTIAGO RIVERA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8260 SW 210TH ST APT 215
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-3476
Mailing Address - Country:US
Mailing Address - Phone:701-391-4009
Mailing Address - Fax:
Practice Address - Street 1:7875 NW 12TH ST STE 118
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1815
Practice Address - Country:US
Practice Address - Phone:786-505-4449
Practice Address - Fax:786-667-3733
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician