Provider Demographics
NPI:1831641000
Name:RIVAS-PEREZ, JOSE ANTONIO (LCSW)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
Last Name:RIVAS-PEREZ
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 1:3504 N SOUTHPORT AVE # 4S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6877
Mailing Address - Country:US
Mailing Address - Phone:248-933-5823
Mailing Address - Fax:
Practice Address - Street 1:999 CIVIC CENTER DR
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-3224
Practice Address - Country:US
Practice Address - Phone:847-588-8476
Practice Address - Fax:847-588-8454
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0189131041C0700X
IL10011631041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool