Provider Demographics
NPI:1396073375
Name:RIVERA, PEDRO LUIS
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:LUIS
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:PO BOX 571
Mailing Address - Street 2:
Mailing Address - City:LAS PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00771-0571
Mailing Address - Country:US
Mailing Address - Phone:787-314-9053
Mailing Address - Fax:
Practice Address - Street 1:CALLE CRUZ ORTIZ STELLA 126
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-649-6773
Practice Address - Fax:787-733-2813
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3446103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling