Provider Demographics
NPI:1538564117
Name:RIVERA, JORGE
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:RIVERA
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 1:83 CALLE CENTRAL
Mailing Address - Street 2:
Mailing Address - City:CATANO
Mailing Address - State:PR
Mailing Address - Zip Code:00962-4107
Mailing Address - Country:US
Mailing Address - Phone:787-238-0478
Mailing Address - Fax:
Practice Address - Street 1:URB SANTA ROSA CARR 174
Practice Address - Street 2:SUITE 16 BLOCK 11
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-238-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-25
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6557103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical