Provider Demographics
NPI:1902581440
Name:RIVERS, FREDRICK L
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:L
Last Name:RIVERS
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 1:1111 W TOKAY ST STE A
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3965
Mailing Address - Country:US
Mailing Address - Phone:209-412-2388
Mailing Address - Fax:
Practice Address - Street 1:1111 W TOKAY ST STE A
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3965
Practice Address - Country:US
Practice Address - Phone:209-412-2388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health