Healthcare Provider Details

I. General information

NPI: 1619433349
Provider Name (Legal Business Name): ROBERT CHARLES RIVERA CASAC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COMMERCIAL PL
NEWBURGH NY
12550-5306
US

IV. Provider business mailing address

121 GRAND AVE
MIDDLETOWN NY
10940-3803
US

V. Phone/Fax

Practice location:
  • Phone: 845-220-2146
  • Fax: 845-561-3913
Mailing address:
  • Phone: 845-518-5567
  • Fax: 845-561-3913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number35037
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: