Provider Demographics
NPI:1033581749
Name:RIVERA, LISA (MA, LPC, LAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MA, LPC, LAC
Other - Prefix:
Other - First Name:LALO
Other - Middle Name:
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LPC, LAC
Mailing Address - Street 1:1225 KEN PRATT BLVD
Mailing Address - Street 2:STE. 200
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6518
Mailing Address - Country:US
Mailing Address - Phone:303-772-3382
Mailing Address - Fax:
Practice Address - Street 1:1225 KEN PRATT BLVD
Practice Address - Street 2:STE. 200
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6518
Practice Address - Country:US
Practice Address - Phone:303-772-3382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC0011444101Y00000X
COACD0000527101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)