Provider Demographics
NPI:1679178057
Name:RIVERA TORRES, KERYNNE ISHBEL
Entity type:Individual
Prefix:
First Name:KERYNNE
Middle Name:ISHBEL
Last Name:RIVERA TORRES
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 1:6815 W UNIVERSITY AVE APT 5102
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2299
Mailing Address - Country:US
Mailing Address - Phone:850-781-4063
Mailing Address - Fax:
Practice Address - Street 1:6815 W UNIVERSITY AVE APT 5102
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2299
Practice Address - Country:US
Practice Address - Phone:850-781-4063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X, 106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032021OtherFLORIDA BLUE