Provider Demographics
NPI:1295162204
Name:RIVERA, MARITZA
Entity type:Individual
Prefix:
First Name:MARITZA
Middle Name:
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 1:2928 W 36TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-1410
Mailing Address - Country:US
Mailing Address - Phone:718-372-3300
Mailing Address - Fax:718-996-8758
Practice Address - Street 1:2928 W 36TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1410
Practice Address - Country:US
Practice Address - Phone:718-372-3300
Practice Address - Fax:718-996-8758
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
165564937103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244220Medicaid