Provider Demographics
NPI:1942235395
Name:RIVERA-BRAHM, MARY H (LSW, LICDC-S LCPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:H
Last Name:RIVERA-BRAHM
Suffix:
Gender:F
Credentials:LSW, LICDC-S LCPC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LSW, LICDC-S LCPC
Mailing Address - Street 1:454 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1227
Mailing Address - Country:US
Mailing Address - Phone:440-409-8507
Mailing Address - Fax:
Practice Address - Street 1:454 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-1227
Practice Address - Country:US
Practice Address - Phone:440-409-8507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH965683101YA0400X
OHS-0021092104100000X
IL180006589101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker