Provider Demographics
NPI:1720785983
Name:RIVERA, EDWIN JR
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:RIVERA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 RESEARCH CT STE 800
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6606
Mailing Address - Country:US
Mailing Address - Phone:678-749-7600
Mailing Address - Fax:
Practice Address - Street 1:5050 RESEARCH CT STE 800
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6606
Practice Address - Country:US
Practice Address - Phone:678-749-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007538101YM0800X
GALPC014547101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health