Provider Demographics
NPI:1619624442
Name:RIVERA, LISA NICHOLE (LMSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:NICHOLE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S MAIN ST STE 249505S
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1206
Mailing Address - Country:US
Mailing Address - Phone:575-527-5886
Mailing Address - Fax:
Practice Address - Street 1:505 S MAIN ST STE 249
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1243
Practice Address - Country:US
Practice Address - Phone:575-527-5886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2025-00481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM35650338Medicaid