Provider Demographics
NPI:1417773466
Name:RIVERA, GRACE BETTY I
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:BETTY
Last Name:RIVERA
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 RIVERSIDE DR APT D
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-1238
Mailing Address - Country:US
Mailing Address - Phone:937-716-0435
Mailing Address - Fax:
Practice Address - Street 1:2522 NUTTER PARK DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-3500
Practice Address - Country:US
Practice Address - Phone:859-282-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHBACB1205385106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician