Provider Demographics
NPI:1063204907
Name:RIVAS, MICHAEL KEN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEN
Last Name:RIVAS
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 1:349 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-2675
Mailing Address - Country:US
Mailing Address - Phone:630-597-6340
Mailing Address - Fax:224-769-7210
Practice Address - Street 1:1135 BOWES RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-5541
Practice Address - Country:US
Practice Address - Phone:847-931-6234
Practice Address - Fax:224-769-7210
Is Sole Proprietor?:No
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health