Provider Demographics
NPI:1790001451
Name:RIVERA, GUADALUPE (CASAC)
Entity Type:Individual
Prefix:MR
First Name:GUADALUPE
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 1:60 KINGSLAND AVE #3B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211
Mailing Address - Country:US
Mailing Address - Phone:347-671-1570
Mailing Address - Fax:
Practice Address - Street 1:810 CLASSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238
Practice Address - Country:US
Practice Address - Phone:718-230-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24182101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)