Provider Demographics
NPI:1205445269
Name:PADRON RIVERO, JENNY LADYES (BACB572667)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:LADYES
Last Name:PADRON RIVERO
Suffix:
Gender:F
Credentials:BACB572667
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 CYPRESS RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-6308
Mailing Address - Country:US
Mailing Address - Phone:786-290-1528
Mailing Address - Fax:
Practice Address - Street 1:3309 W WATERS AVE STE A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2766
Practice Address - Country:US
Practice Address - Phone:813-898-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-127932106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBACB572667Medicaid