Healthcare Provider Details

I. General information

NPI: 1275692725
Provider Name (Legal Business Name): BEVERLY A HERMAN RIVERA RD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 DEAN ST
GLEN ROCK NJ
07452
US

IV. Provider business mailing address

140 DEAN ST
GLEN ROCK NJ
07452
US

V. Phone/Fax

Practice location:
  • Phone: 201-445-1460
  • Fax: 201-445-1460
Mailing address:
  • Phone: 201-445-1460
  • Fax: 201-445-1460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number2041-0164
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number882506CDR
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: