Provider Demographics
NPI:1932692100
Name:RIVERA, GENESIS MINNELLY
Entity Type:Individual
Prefix:MS
First Name:GENESIS
Middle Name:MINNELLY
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 LEMOINE AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6210
Mailing Address - Country:US
Mailing Address - Phone:201-298-3737
Mailing Address - Fax:
Practice Address - Street 1:2460 LEMOINE AVE STE 306
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6210
Practice Address - Country:US
Practice Address - Phone:201-298-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-23-70293103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst