Provider Demographics
NPI:1043651821
Name:RIVERA, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
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 1:10828 MASSASOIT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2415
Mailing Address - Country:US
Mailing Address - Phone:773-653-3095
Mailing Address - Fax:
Practice Address - Street 1:1010 N HOOKER ST STE 301
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-4633
Practice Address - Country:US
Practice Address - Phone:312-943-3600
Practice Address - Fax:866-410-9192
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
160005840225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant