Provider Demographics
NPI:1285054734
Name:RIVERA, WENDELL P (PHD, LCSW-R)
Entity type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:P
Last Name:RIVERA
Suffix:
Gender:M
Credentials:PHD, LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1917
Mailing Address - Country:US
Mailing Address - Phone:716-998-1162
Mailing Address - Fax:
Practice Address - Street 1:149 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1917
Practice Address - Country:US
Practice Address - Phone:716-998-1162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR069230-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker