Provider Demographics
NPI:1467203380
Name:RIVERS, TRACSTON
Entity Type:Individual
Prefix:
First Name:TRACSTON
Middle Name:
Last Name:RIVERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 BURNSIDE AVE APT B7
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-1577
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 HARTLAND ST STE 108
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3259
Practice Address - Country:US
Practice Address - Phone:877-943-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician