Provider Demographics
NPI:1396361838
Name:RIVERO GONZALEZ, LISY (BCABA)
Entity type:Individual
Prefix:MISS
First Name:LISY
Middle Name:
Last Name:RIVERO GONZALEZ
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 SW 147TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6126
Mailing Address - Country:US
Mailing Address - Phone:786-372-5051
Mailing Address - Fax:
Practice Address - Street 1:814 SW 147TH AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-6126
Practice Address - Country:US
Practice Address - Phone:786-372-5051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-21
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-116037106S00000X
FL0-25-15784106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1061491000Medicaid