Provider Demographics
NPI:1720580616
Name:PANTOJA, GRACE RYBICKI (BCBA)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:RYBICKI
Last Name:PANTOJA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:THERESE
Other - Last Name:RYBICKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30330 HICKEY RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48051-3911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30330 HICKEY RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051-3911
Practice Address - Country:US
Practice Address - Phone:586-421-4062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156F00000X, 103K00000X
MI7401001483103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No156F00000XEye and Vision Services ProvidersTechnician/Technologist