Provider Demographics
NPI:1730802745
Name:RIVERS, KEISHA NICOLE
Entity type:Individual
Prefix:PROF
First Name:KEISHA
Middle Name:NICOLE
Last Name:RIVERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 OLD COUNTRY RD
Mailing Address - Street 2:SUITE C103N
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590
Mailing Address - Country:US
Mailing Address - Phone:631-375-8593
Mailing Address - Fax:
Practice Address - Street 1:64 WRIGHT STREET
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-1170
Practice Address - Country:US
Practice Address - Phone:631-375-8593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1796479174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist