Provider Demographics
NPI:1487151684
Name:RIVERA, KRYSTAL (MA CF-SLP)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MA CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2337 NANSEN AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4312
Mailing Address - Country:US
Mailing Address - Phone:407-780-4843
Mailing Address - Fax:
Practice Address - Street 1:1000 W BROADWAY ST STE 214
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765
Practice Address - Country:US
Practice Address - Phone:407-359-5693
Practice Address - Fax:407-792-5693
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024929200Medicaid