Provider Demographics
NPI:1588939102
Name:BENNETT, RIVA XYLINA (LMHC, BCBA)
Entity type:Individual
Prefix:MS
First Name:RIVA
Middle Name:XYLINA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMHC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 EDELWEISS ST E
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33974-0434
Mailing Address - Country:US
Mailing Address - Phone:239-368-3154
Mailing Address - Fax:239-368-3154
Practice Address - Street 1:1109 EDELWEISS ST E
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33974-0434
Practice Address - Country:US
Practice Address - Phone:239-322-6894
Practice Address - Fax:239-368-3154
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 8627101YM0800X
FL1-08-4732103K00000X
FL1001170103TS0200X
NJ00357584103TS0200X
NJSW 47601104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000531000OtherMEDICAID DD WAIVER PROVIDER
FL000648800OtherMEDICAID DD WAIVER PROVIDER