Provider Demographics
NPI:1841702966
Name:RIVERA, GRACE JOSEPHINE (LSW)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:JOSEPHINE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 SCHAEFER AVE
Mailing Address - Street 2:
Mailing Address - City:ORADELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07649-2517
Mailing Address - Country:US
Mailing Address - Phone:201-261-1873
Mailing Address - Fax:
Practice Address - Street 1:17-07 ROMAINE ST
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2150
Practice Address - Country:US
Practice Address - Phone:201-797-2660
Practice Address - Fax:201-797-5025
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06321500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health