Basic Information
| Provider Information | |||||||||
| NPI: | 1811548647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1219 MAPLEWOOD RD | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017663280 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 114 E CRANDALL AVE | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726013628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707418484 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2019 | ||||||||
| LastUpdateDate: | 07/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | M2576 | AR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 2576-M | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 239447795 | 05 | AR | MEDICAID |