Provider Demographics
NPI:1033943147
Name:RIVERO AVILES, RAUL JESUS
Entity type:Individual
Prefix:
First Name:RAUL
Middle Name:JESUS
Last Name:RIVERO AVILES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 S PARK RD APT 209
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8741
Mailing Address - Country:US
Mailing Address - Phone:305-458-9168
Mailing Address - Fax:
Practice Address - Street 1:450 S PARK RD APT 209
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8741
Practice Address - Country:US
Practice Address - Phone:305-458-9168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-360374106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician