Provider Demographics
NPI:1831128347
Name:RIVERA, ANGEL M (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ANGEL
Middle Name:M
Last Name:RIVERA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 N KROME AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-4409
Mailing Address - Country:US
Mailing Address - Phone:786-504-8070
Mailing Address - Fax:786-504-8073
Practice Address - Street 1:922 N KROME AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4409
Practice Address - Country:US
Practice Address - Phone:786-382-3507
Practice Address - Fax:786-504-8070
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 41141041C0700X
FLSW4114101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101YM0800XOtherTAXONOMY
FL011062900Medicaid
FL011062900Medicaid