Healthcare Provider Details

I. General information

NPI: 1740197599
Provider Name (Legal Business Name): CELIDA INES RIVERA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 W JIMMIE LEEDS RD STE 305
GALLOWAY NJ
08205-9418
US

IV. Provider business mailing address

626 1ST ST
NORTHFIELD NJ
08225-2034
US

V. Phone/Fax

Practice location:
  • Phone: 609-916-6500
  • Fax: 609-798-0112
Mailing address:
  • Phone: 973-650-5196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00682000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: