Healthcare Provider Details

I. General information

NPI: 1306612551
Provider Name (Legal Business Name): MELISSA RIVERA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 E MAIN ST
TUCKERTON NJ
08087-2618
US

IV. Provider business mailing address

162 E MAIN ST
TUCKERTON NJ
08087-2618
US

V. Phone/Fax

Practice location:
  • Phone: 732-503-8543
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: