MEDICARE: RAEANN RIVERA LCSW

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	1041C0700X	Clinical Social Worker	C-09609	NM

General Provider Information

NPI Number	:	1619281664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAEANN RIVERA LCSW

Provider Business Mailing Address
First Line	:	2109 ALHAMBRA AVE SW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87104-1601
Country	:	US
Telephone Number	:	575-208-4662
Fax Number	:	505-212-0976

Provider Business Practice Location Address
First Line	:	2109 ALHAMBRA AVE SW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87104-1601
Country	:	US
Telephone Number	:	575-208-4662
Fax Number	:	505-212-0976

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

Provider Enumeration Date	:	08/02/2010
Last Update Date	:	04/22/2021

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