Basic Information
Provider Information | |||||||||
NPI: | 1437696457 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ACOSTA-RIVERA | ||||||||
FirstName: | GILLIE | ||||||||
MiddleName: | JOHANNA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 267 LAKE DAVENPORT CIR | ||||||||
Address2: |   | ||||||||
City: | DAVENPORT | ||||||||
State: | FL | ||||||||
PostalCode: | 338377527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4079528880 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1413 TECH BLVD STE 122 | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336197822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8558326727 | ||||||||
FaxNumber: | 7726759100 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2017 | ||||||||
LastUpdateDate: | 01/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-19-36293 |   | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.