Provider Demographics
NPI:1588391148
Name:RIVERA, THERESA RENEE (NMT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:RENEE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 W SANTA BARBARA AVE
Mailing Address - Street 2:
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96929-5304
Mailing Address - Country:US
Mailing Address - Phone:671-687-8079
Mailing Address - Fax:
Practice Address - Street 1:643 CHALAN SAN ANTONIO STE 108
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3644
Practice Address - Country:US
Practice Address - Phone:671-687-8079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0024273225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist