Provider Demographics
NPI:1437405842
Name:RIVERA, PABLO R (LCSW-C)
Entity Type:Individual
Prefix:MR
First Name:PABLO
Middle Name:R
Last Name:RIVERA
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 80 BOX 13636
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-0039
Mailing Address - Country:US
Mailing Address - Phone:240-921-9958
Mailing Address - Fax:
Practice Address - Street 1:375 MDG
Practice Address - Street 2:310 W LOSEY ST
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225-5252
Practice Address - Country:US
Practice Address - Phone:618-256-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD182491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical