=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962913657
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIMBERLY RIVERA LCSW, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2017
-----------------------------------------------------
Last Update Date | 10/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 FOREST AVE
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07006-5208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-307-0182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 59 SUNNYSIDE RD
-----------------------------------------------------
City | WEST ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07052-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KIMBERLY C RIVERA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 973-307-0182
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC05624400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------