Provider Demographics
NPI:1508396532
Name:RIVERA, MATTHEW MARCUS (EMR)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MARCUS
Last Name:RIVERA
Suffix:
Gender:M
Credentials:EMR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2363 CALLE DEL SUR
Mailing Address - Street 2:
Mailing Address - City:MESILLA
Mailing Address - State:NM
Mailing Address - Zip Code:88463
Mailing Address - Country:US
Mailing Address - Phone:575-527-2566
Mailing Address - Fax:
Practice Address - Street 1:2363 CALLE DEL SUR
Practice Address - Street 2:
Practice Address - City:MESILLA
Practice Address - State:NM
Practice Address - Zip Code:88463
Practice Address - Country:US
Practice Address - Phone:575-527-2566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM509424993247200000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other