Provider Demographics
NPI:1023998143
Name:RIVAS PANEQUE, LIDIA MARIA
Entity type:Individual
Prefix:
First Name:LIDIA
Middle Name:MARIA
Last Name:RIVAS PANEQUE
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 1:15211 SW 173RD LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33187-4333
Mailing Address - Country:US
Mailing Address - Phone:310-706-5609
Mailing Address - Fax:305-699-3590
Practice Address - Street 1:15211 SW 173RD LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33187-4333
Practice Address - Country:US
Practice Address - Phone:310-706-5609
Practice Address - Fax:305-699-3590
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-469647106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician