MEDICARE: CUSTOMIZED BEHAVIORAL HEALTHCARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6935	OH

General Provider Information

NPI Number	:	1447786447
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSTOMIZED BEHAVIORAL HEALTHCARE

Provider Business Mailing Address
First Line	:	8842 CRESTWATER DR
Second Line	:
City	:	GALLOWAY
State	:	OH
Zip	:	43119-9470
Country	:	US
Telephone Number	:	614-330-8834
Fax Number	:

Provider Business Practice Location Address
First Line	:	3244 HENDERSON RD STE 4
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43220-7300
Country	:	US
Telephone Number	:	614-664-3175
Fax Number	:	614-386-1692

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ANTHONY LAMONT RIVERS
Credential	:	PSY.D.
Telephone Number	:	614-664-3175

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	11/09/2023

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