Provider Demographics
NPI:1861191231
Name:RIVERS, DOMENIQUE NICOLE
Entity type:Individual
Prefix:
First Name:DOMENIQUE
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 1:75 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-2003
Mailing Address - Country:US
Mailing Address - Phone:516-666-3764
Mailing Address - Fax:
Practice Address - Street 1:138 S 1ST ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4930
Practice Address - Country:US
Practice Address - Phone:914-768-3537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-P120263-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health