Provider Demographics
NPI:1720567506
Name:RIVERS, SYDNY VANESSA (TLLP)
Entity Type:Individual
Prefix:
First Name:SYDNY
Middle Name:VANESSA
Last Name:RIVERS
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3941 E NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 N CENTER ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1277
Practice Address - Country:US
Practice Address - Phone:313-656-4052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-12
Last Update Date:2022-11-07
Deactivation Date:2019-05-06
Deactivation Code:
Reactivation Date:2021-08-03
Provider Licenses
StateLicense IDTaxonomies
MI6362009331103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist