Provider Demographics
NPI:1801924824
Name:RIVELA, LAURA TERESA (LCSW RBCD)
Entity type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:TERESA
Last Name:RIVELA
Suffix:
Gender:F
Credentials:LCSW RBCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 VERBENA DRIVE
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725
Mailing Address - Country:US
Mailing Address - Phone:631-543-7604
Mailing Address - Fax:631-543-7604
Practice Address - Street 1:50 ROUTE 111
Practice Address - Street 2:SUITE 204
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-979-5330
Practice Address - Fax:631-979-5330
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0577831104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNE6961Medicare ID - Type Unspecified