Provider Demographics
NPI:1346790946
Name:RIVERA SERRANO, YARITZA (MA SLP)
Entity type:Individual
Prefix:
First Name:YARITZA
Middle Name:
Last Name:RIVERA SERRANO
Suffix:
Gender:F
Credentials:MA SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 RICARDO ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-3334
Mailing Address - Country:US
Mailing Address - Phone:407-307-6182
Mailing Address - Fax:220-506-7222
Practice Address - Street 1:1516 RICARDO ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-3334
Practice Address - Country:US
Practice Address - Phone:407-307-6182
Practice Address - Fax:229-506-7222
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16419235Z00000X
FL7846235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003225703Medicaid
FL019876800Medicaid