Provider Demographics
NPI:1609032754
Name:RIVERA, JORGE (CASAC)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1688 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3533
Mailing Address - Country:US
Mailing Address - Phone:718-447-5700
Mailing Address - Fax:718-442-8945
Practice Address - Street 1:1688 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3533
Practice Address - Country:US
Practice Address - Phone:718-447-5700
Practice Address - Fax:718-442-8945
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCASAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)