Provider Demographics
NPI:1710465026
Name:DEGRAFFENREID, ROBERT SHAUN (RBT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:SHAUN
Last Name:DEGRAFFENREID
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 S BROAD ST APT A5
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-3538
Mailing Address - Country:US
Mailing Address - Phone:862-216-1193
Mailing Address - Fax:
Practice Address - Street 1:428 S BROAD ST APT A5
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-3538
Practice Address - Country:US
Practice Address - Phone:862-216-1193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRBT-18-50310106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician