Provider Demographics
NPI:1568175776
Name:RIVERA AGOSTO, JESLIE
Entity type:Individual
Prefix:MISS
First Name:JESLIE
Middle Name:
Last Name:RIVERA AGOSTO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 INFIELD CT
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8026
Mailing Address - Country:US
Mailing Address - Phone:704-799-6824
Mailing Address - Fax:704-799-6825
Practice Address - Street 1:1643 WARWICK AVE STE 104
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02889-1525
Practice Address - Country:US
Practice Address - Phone:855-295-3276
Practice Address - Fax:888-588-2752
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2491103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst