Healthcare Provider Details

I. General information

NPI: 1114840261
Provider Name (Legal Business Name): SAGE NICHOLAS RIVERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 BOWDEN RD
CEDAR GROVE NJ
07009-1523
US

IV. Provider business mailing address

196 BOWDEN RD
CEDAR GROVE NJ
07009-1523
US

V. Phone/Fax

Practice location:
  • Phone: 623-249-1540
  • Fax:
Mailing address:
  • Phone: 623-249-1540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR01306700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: