Provider Demographics
NPI:1164649463
Name:RIVERA, ANA MARIELLA (LICSW)
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:MARIELLA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-2305
Mailing Address - Country:US
Mailing Address - Phone:312-396-3963
Mailing Address - Fax:
Practice Address - Street 1:241 CLEVELAND AVE S
Practice Address - Street 2:SUITE A7
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1208
Practice Address - Country:US
Practice Address - Phone:612-396-3963
Practice Address - Fax:612-871-1058
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
17718104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker