Provider Demographics
NPI:1437734472
Name:RIVERA, KASSANDRA YLISSA (LMSW)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:YLISSA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10641 MICROLITH RD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-5479
Mailing Address - Country:US
Mailing Address - Phone:505-280-8844
Mailing Address - Fax:
Practice Address - Street 1:2440 LOUISIANA BLVD NE STE 300
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4394
Practice Address - Country:US
Practice Address - Phone:505-302-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-11277104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker