Provider Demographics
NPI:1376813360
Name:RIVERA, RALPH M (CASACT)
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:M
Last Name:RIVERA
Suffix:
Gender:M
Credentials:CASACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 PORT RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1704
Mailing Address - Country:US
Mailing Address - Phone:718-981-8117
Mailing Address - Fax:718-981-9344
Practice Address - Street 1:263 PORT RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1704
Practice Address - Country:US
Practice Address - Phone:718-981-8117
Practice Address - Fax:718-981-9344
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24694101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)