Provider Demographics
NPI:1952725186
Name:RIVAS-CARRILLO, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:RIVAS-CARRILLO
Suffix:
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 1:100 TRIMBLE AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-1214
Mailing Address - Country:US
Mailing Address - Phone:201-640-7228
Mailing Address - Fax:
Practice Address - Street 1:119 TOMPKINS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2601
Practice Address - Country:US
Practice Address - Phone:646-357-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health