MEDICARE: NECOLE RIVERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	37382	TX
2	225X00000X	Occupational Therapist	111722	TX
3	225XP0200X	Pediatric Occupational Therapist	111722	TX
4	103TC0700X	Clinical Psychologist	37382	TX

General Provider Information

NPI Number	:	1053468603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NECOLE RIVERS

Provider Business Mailing Address
First Line	:	1506 DAVIS MILL LN
Second Line	:
City	:	SALADO
State	:	TX
Zip	:	76571-5990
Country	:	US
Telephone Number	:	254-338-3175
Fax Number	:	254-265-7061

Provider Business Practice Location Address
First Line	:	1023 CANYON CREEK DR STE 100
Second Line	:
City	:	TEMPLE
State	:	TX
Zip	:	76502-3278
Country	:	US
Telephone Number	:	254-338-3175
Fax Number	:	254-265-7061

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	01/13/2025

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1063948032 — NECOLE RIVERS LLC
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Directions to “ NECOLE RIVERS ” Practice Location

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