Provider Demographics
NPI:1508417619
Name:RIVERA, LUIS T (LMSW)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:T
Last Name:RIVERA
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 OLD BLUE HILLS RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06422-3005
Mailing Address - Country:US
Mailing Address - Phone:203-231-2551
Mailing Address - Fax:
Practice Address - Street 1:949 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3142
Practice Address - Country:US
Practice Address - Phone:203-878-6365
Practice Address - Fax:203-301-2397
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT119111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004039244Medicaid