Basic Information
| Provider Information | |||||||||
| NPI: | 1154746709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | CHRISTINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142021102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168991659 | ||||||||
| FaxNumber: | 7168981313 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142021102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168991659 | ||||||||
| FaxNumber: | 7168981313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2014 | ||||||||
| LastUpdateDate: | 02/19/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 086189 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 830382654 | 05 | NY | MEDICAID |