Provider Demographics
NPI:1467559013
Name:RIVERA, AMY MARIE NELSON (MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE NELSON
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LPC
Mailing Address - Street 1:85 GOLF CREST DR
Mailing Address - Street 2:SUITE 309
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-2698
Mailing Address - Country:US
Mailing Address - Phone:404-918-0816
Mailing Address - Fax:404-601-7495
Practice Address - Street 1:85 GOLF CREST DR
Practice Address - Street 2:SUITE 309
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-2698
Practice Address - Country:US
Practice Address - Phone:404-918-0816
Practice Address - Fax:404-601-7495
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004629101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA095860337AMedicaid