Provider Demographics
NPI:1366900987
Name:RIVERA, SUZIE (BS)
Entity type:Individual
Prefix:
First Name:SUZIE
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:SUZIE
Other - Middle Name:
Other - Last Name:MARVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:79 N CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14604-1407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:79 N CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604-1407
Practice Address - Country:US
Practice Address - Phone:585-546-7220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY913734747OtherNYS DRIVERS LICENSE NUMBER