Provider Demographics
NPI:1427409952
Name:RIVERA, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
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 1:2801 GARDEN CITY BLVD
Mailing Address - Street 2:UNIT 102
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014
Mailing Address - Country:US
Mailing Address - Phone:540-598-5775
Mailing Address - Fax:540-767-2669
Practice Address - Street 1:2801 GARDEN CITY BLVD SE
Practice Address - Street 2:UNIT 102
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-4454
Practice Address - Country:US
Practice Address - Phone:540-598-5775
Practice Address - Fax:540-767-2669
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006486101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional