Provider Demographics
NPI:1003323874
Name:RIVERA, ERIN WALLEY (LCSW)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:WALLEY
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 LADY ELAINE DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-5821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5245 N SOCRUM LOOP RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4253
Practice Address - Country:US
Practice Address - Phone:863-859-1446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL144601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical