Healthcare Provider Details

I. General information

NPI: 1932379153
Provider Name (Legal Business Name): EDELMIRO RIVERA JR. LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 E 142ND ST
BRONX NY
10454-1723
US

IV. Provider business mailing address

781 E 142ND ST
BRONX NY
10454-1723
US

V. Phone/Fax

Practice location:
  • Phone: 718-993-1400
  • Fax: 718-993-0647
Mailing address:
  • Phone: 718-993-1400
  • Fax: 718-993-0647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR--072576
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: