Basic Information
| Provider Information | |||||||||
| NPI: | 1437405842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | PABLO | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PSC 80 BOX 13636 | ||||||||
| Address2: | |||||||||
| City: | APO | ||||||||
| State: | AP | ||||||||
| PostalCode: | 963670039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2409219958 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 375 MDG | ||||||||
| Address2: | 310 W LOSEY ST | ||||||||
| City: | SCOTT AFB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622255252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182569355 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2012 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 18249 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.