Provider Demographics
NPI:1669151965
Name:CARRERA RIVADENEIRA, MARTIN ALEJANDRO (LMSW)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:ALEJANDRO
Last Name:CARRERA RIVADENEIRA
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8827 208TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2258
Mailing Address - Country:US
Mailing Address - Phone:917-981-0903
Mailing Address - Fax:
Practice Address - Street 1:8837 208TH ST
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2258
Practice Address - Country:US
Practice Address - Phone:917-981-0903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119096-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker