Provider Demographics
NPI:1154814614
Name:GRYBOS, ELISE MARIE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:MARIE
Last Name:GRYBOS
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 1:702 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-1908
Mailing Address - Country:US
Mailing Address - Phone:570-809-4397
Mailing Address - Fax:
Practice Address - Street 1:702 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-1908
Practice Address - Country:US
Practice Address - Phone:570-809-4397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-10
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001127103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst