Provider Demographics
NPI:1740762822
Name:RIVERS, GARNETTE CAMILLE
Entity type:Individual
Prefix:
First Name:GARNETTE
Middle Name:CAMILLE
Last Name:RIVERS
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 1:907 W CADDO ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020-4201
Mailing Address - Country:US
Mailing Address - Phone:918-633-6279
Mailing Address - Fax:
Practice Address - Street 1:907 W CADDO ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-4201
Practice Address - Country:US
Practice Address - Phone:918-633-6279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK315898171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1OtherPRSS