Healthcare Provider Details

I. General information

NPI: 1043777816
Provider Name (Legal Business Name): JEANETTE RIVERA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 STATE ROUTE 17M STE 4
MONROE NY
10950-3444
US

IV. Provider business mailing address

3 DAWN CT
CHESTER NY
10918-2518
US

V. Phone/Fax

Practice location:
  • Phone: 845-547-0479
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number087996
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: