Healthcare Provider Details

I. General information

NPI: 1023847746
Provider Name (Legal Business Name): KELLIE RENE RIVERA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11515 SUTPHIN BLVD
JAMAICA NY
11434-1020
US

IV. Provider business mailing address

4330 48TH ST APT F3
SUNNYSIDE NY
11104-1630
US

V. Phone/Fax

Practice location:
  • Phone: 718-765-6009
  • Fax:
Mailing address:
  • Phone: 917-570-8987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number103539
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: