Provider Demographics
NPI:1346847092
Name:RIVERA, STEPHANIE LEE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEE
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 1:3410 KINGSBRIDGE AVE APT 32E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-4040
Mailing Address - Country:US
Mailing Address - Phone:646-702-3628
Mailing Address - Fax:
Practice Address - Street 1:3410 KINGSBRIDGE AVE APT 32E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-4040
Practice Address - Country:US
Practice Address - Phone:646-702-3628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
109734104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker