MEDICARE: SANDY V 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	44SC05282800	NJ
2	1041C0700X	Clinical Social Worker	076430-1	NY

General Provider Information

NPI Number	:	1801949789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDY V RIVERA LCSW

Provider Business Mailing Address
First Line	:	PO BOX 528
Second Line	:
City	:	CORNWALL
State	:	NY
Zip	:	12518-0528
Country	:	US
Telephone Number	:	845-220-3100
Fax Number	:	845-534-2940

Provider Business Practice Location Address
First Line	:	147 LAKE STREET
Second Line	:
City	:	NEWBURGH
State	:	NY
Zip	:	12550-5242
Country	:	US
Telephone Number	:	845-563-8000
Fax Number	:

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

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	07/21/2011

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