Provider Demographics
NPI:1467269829
Name:RIVAS ORTIZ, MARIO RODELIO
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:RODELIO
Last Name:RIVAS ORTIZ
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 1:85 WILMOT RD
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-4312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2666 STATE ST STE A3
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06517-2232
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician