Provider Demographics
NPI:1962934133
Name:RIVERA, VELVET
Entity type:Individual
Prefix:
First Name:VELVET
Middle Name:
Last Name:RIVERA
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 1:2184 SE SUNFLOWER ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4878
Mailing Address - Country:US
Mailing Address - Phone:203-804-7368
Mailing Address - Fax:305-290-3081
Practice Address - Street 1:514 S HUNT CLUB BLVD
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-4948
Practice Address - Country:US
Practice Address - Phone:407-613-2335
Practice Address - Fax:866-610-0580
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108564000Medicaid