Provider Demographics
NPI:1780675868
Name:RIVERA, LISA JAN (LCSW-R)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JAN
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 BUCKLEY PL
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-5810
Mailing Address - Country:US
Mailing Address - Phone:917-257-5880
Mailing Address - Fax:
Practice Address - Street 1:17 W MERRICK RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3873
Practice Address - Country:US
Practice Address - Phone:917-257-5880
Practice Address - Fax:516-868-3374
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRNY0688691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical