Provider Demographics
NPI:1962110254
Name:RIVAS, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:RIVAS
Suffix:
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 1:2131 NE 13TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-4406
Mailing Address - Country:US
Mailing Address - Phone:239-336-9764
Mailing Address - Fax:
Practice Address - Street 1:1342 SE 46TH LN
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-8617
Practice Address - Country:US
Practice Address - Phone:239-961-3032
Practice Address - Fax:239-310-2049
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician