Provider Demographics
NPI:1972351294
Name:RIVERS, JEROLD
Entity type:Individual
Prefix:
First Name:JEROLD
Middle Name:
Last Name:RIVERS
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 1:332 HOLBROOK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1815
Mailing Address - Country:US
Mailing Address - Phone:631-504-7672
Mailing Address - Fax:
Practice Address - Street 1:770 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5750
Practice Address - Country:US
Practice Address - Phone:631-392-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)