Healthcare Provider Details

I. General information

NPI: 1578135307
Provider Name (Legal Business Name): CAITLIN GRACE RIVENBARK MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 REDFIELD ST STE 105
DORCHESTER MA
02122-3640
US

IV. Provider business mailing address

50 REDFIELD ST STE 105
DORCHESTER MA
02122-3640
US

V. Phone/Fax

Practice location:
  • Phone: 774-206-1125
  • Fax:
Mailing address:
  • Phone: 774-206-1125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: