Provider Demographics
NPI:1306307863
Name:RIVENBARK, LANEY LEANNE
Entity type:Individual
Prefix:
First Name:LANEY
Middle Name:LEANNE
Last Name:RIVENBARK
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 1:19 WATER ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:MA
Mailing Address - Zip Code:01749-2309
Mailing Address - Country:US
Mailing Address - Phone:617-763-1476
Mailing Address - Fax:
Practice Address - Street 1:345 GREENWOOD ST STE A
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01607-1767
Practice Address - Country:US
Practice Address - Phone:508-363-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MATJX981442947OtherBLUE CROSS, BLUE SHEILD