Provider Demographics
NPI:1083493175
Name:RIVERA, CARMEN (BT)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561-5314
Mailing Address - Country:US
Mailing Address - Phone:630-590-5571
Mailing Address - Fax:
Practice Address - Street 1:390 E CONGRESS PKWY STE M
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6207
Practice Address - Country:US
Practice Address - Phone:779-284-0347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician