Provider Demographics
NPI:1265663140
Name:RIVEROS, ROBERTO (PHD, LPC)
Entity Type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:
Last Name:RIVEROS
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:MR
Other - First Name:ROBERTO
Other - Middle Name:
Other - Last Name:RIVEROS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:235 E PONCE DE LEON AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3452
Mailing Address - Country:US
Mailing Address - Phone:770-962-7508
Mailing Address - Fax:678-985-4296
Practice Address - Street 1:235 E. PONCE DE LEON
Practice Address - Street 2:SUITE 120
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030
Practice Address - Country:US
Practice Address - Phone:770-962-7508
Practice Address - Fax:678-985-4296
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004905101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor