Provider Demographics
NPI:1336508191
Name:GREBOUSKI, THOMAS (PHD, BCBA-D)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GREBOUSKI
Suffix:
Gender:M
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 342
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03901-0342
Mailing Address - Country:US
Mailing Address - Phone:603-674-4267
Mailing Address - Fax:
Practice Address - Street 1:1247 WASHINGTON RD STE 25
Practice Address - Street 2:
Practice Address - City:RYE
Practice Address - State:NH
Practice Address - Zip Code:03870-2346
Practice Address - Country:US
Practice Address - Phone:603-674-4267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1-13-12797103K00000X
NH344101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1336508191Medicaid