Provider Demographics
NPI:1588316095
Name:RIVERA-R, LAURA P
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:P
Last Name:RIVERA-R
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 1:172 ELLISON AVE
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-2173
Mailing Address - Country:US
Mailing Address - Phone:516-813-8363
Mailing Address - Fax:
Practice Address - Street 1:172 ELLISON AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-2173
Practice Address - Country:US
Practice Address - Phone:516-813-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000103K00000X, 106E00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst