Provider Demographics
NPI:1225053200
Name:RIVERS, PENELOPE G (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:G
Last Name:RIVERS
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:PENELOPE
Other - Middle Name:
Other - Last Name:RIVERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:1420 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-3619
Mailing Address - Country:US
Mailing Address - Phone:507-235-6070
Mailing Address - Fax:507-235-6074
Practice Address - Street 1:1226 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NEW ULM
Practice Address - State:MN
Practice Address - Zip Code:56073-3454
Practice Address - Country:US
Practice Address - Phone:507-359-2080
Practice Address - Fax:507-359-2086
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN165771041C0700X, 101YM0800X
ORL3738101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1093815136Medicaid