Healthcare Provider Details

I. General information

NPI: 1225960891
Provider Name (Legal Business Name): MARC RIVERA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 HETT AVE
STATEN ISLAND NY
10306-5727
US

IV. Provider business mailing address

121 HETT AVE
STATEN ISLAND NY
10306-5727
US

V. Phone/Fax

Practice location:
  • Phone: 845-800-9473
  • Fax:
Mailing address:
  • Phone: 845-800-9473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number093862
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: