Healthcare Provider Details

I. General information

NPI: 1720567506
Provider Name (Legal Business Name): SYDNY VANESSA RIVERS TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2018
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date: 05/06/2019
Reactivation Date: 08/03/2021

III. Provider practice location address

315 N CENTER ST
NORTHVILLE MI
48167-1277
US

IV. Provider business mailing address

3941 E NEVADA ST
DETROIT MI
48234-1840
US

V. Phone/Fax

Practice location:
  • Phone: 313-656-4052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362009331
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: