Provider Demographics
NPI:1407426919
Name:RIVERA, DERIO MARC (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:DERIO
Middle Name:MARC
Last Name:RIVERA
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 WILD ROSE RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-2551
Mailing Address - Country:US
Mailing Address - Phone:914-319-8518
Mailing Address - Fax:
Practice Address - Street 1:18 WILD ROSE RD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-2551
Practice Address - Country:US
Practice Address - Phone:914-319-8518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4956101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional