Provider Demographics
NPI:1407123532
Name:GRIDLEY, MARY (MS BCBA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:GRIDLEY
Suffix:
Gender:F
Credentials:MS BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 SHADY TREE LN
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1924
Mailing Address - Country:US
Mailing Address - Phone:631-928-8988
Mailing Address - Fax:
Practice Address - Street 1:18 SHADY TREE LN
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1924
Practice Address - Country:US
Practice Address - Phone:631-928-8988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1-07-3586103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst