Provider Demographics
NPI:1013739945
Name:RIVERA RIVERA, YESSICA
Entity type:Individual
Prefix:
First Name:YESSICA
Middle Name:
Last Name:RIVERA 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 1:201 FIREBALL LN
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33917-6536
Mailing Address - Country:US
Mailing Address - Phone:239-240-4929
Mailing Address - Fax:
Practice Address - Street 1:2701 21ST ST SW
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33976-3644
Practice Address - Country:US
Practice Address - Phone:239-240-4929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106E00000X, 106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst