Provider Demographics
NPI:1942573043
Name:RIVERS, MARUKA J (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARUKA
Middle Name:J
Last Name:RIVERS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 WHITTIER DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-1121
Mailing Address - Country:US
Mailing Address - Phone:336-456-3576
Mailing Address - Fax:
Practice Address - Street 1:612 PASTEUR DR
Practice Address - Street 2:209
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1149
Practice Address - Country:US
Practice Address - Phone:336-446-9212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0076071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6009055Medicaid