Provider Demographics
NPI:1518640424
Name:THELUSMA, GRACICA (RBT)
Entity Type:Individual
Prefix:MISS
First Name:GRACICA
Middle Name:
Last Name:THELUSMA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 SUMMERLIN LOOP
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-8868
Mailing Address - Country:US
Mailing Address - Phone:786-916-0644
Mailing Address - Fax:
Practice Address - Street 1:102 PARK PLACE BLVD STE C1
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2358
Practice Address - Country:US
Practice Address - Phone:407-385-0728
Practice Address - Fax:407-386-8988
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician