Provider Demographics
NPI:1053742718
Name:RIVERA, JULIANNE MICHELLE
Entity type:Individual
Prefix:
First Name:JULIANNE
Middle Name:MICHELLE
Last Name:RIVERA
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 1:6121 AVALON RD
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-9745
Mailing Address - Country:US
Mailing Address - Phone:787-552-6972
Mailing Address - Fax:
Practice Address - Street 1:214 S DILLARD ST
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3523
Practice Address - Country:US
Practice Address - Phone:787-552-6972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-06
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ 6745235Z00000X
PR002059235Z00000X
FLSA 13773235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist