Provider Demographics
NPI:1053856989
Name:RIVERA, LISA MARIE
Entity Type:Individual
Prefix:MRS
First Name:LISA MARIE
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 DORRANCE ST
Mailing Address - Street 2:
Mailing Address - City:DANIELSON
Mailing Address - State:CT
Mailing Address - Zip Code:06239-3609
Mailing Address - Country:US
Mailing Address - Phone:860-753-6014
Mailing Address - Fax:
Practice Address - Street 1:50 DORRANCE ST
Practice Address - Street 2:
Practice Address - City:DANIELSON
Practice Address - State:CT
Practice Address - Zip Code:06239-3609
Practice Address - Country:US
Practice Address - Phone:860-753-6014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT96111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical