Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 008809 | CT |
NPI | 1003209198 |
---|---|
Provider Name | Mr. Michael A. Rivera |
First Address | Manchester, CT 06042-1961 |
Second Address | Manchester, CT 06040-5913 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2015 |
Last Update Date | 12/03/2015 |