Provider Demographics
NPI:1609224484
Name:RIVERS, WARREN TODD (REVERAND)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:TODD
Last Name:RIVERS
Suffix:
Gender:M
Credentials:REVERAND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 W CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-3704
Mailing Address - Country:US
Mailing Address - Phone:580-762-1642
Mailing Address - Fax:580-765-7299
Practice Address - Street 1:1501 S PARK LN APT 407
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-6964
Practice Address - Country:US
Practice Address - Phone:580-763-4998
Practice Address - Fax:580-765-7299
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist