Provider Demographics
NPI:1760262174
Name:TEBRAKE, NICHOLAS
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:TEBRAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:TEBRAKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:31 WATSON AVE
Mailing Address - Street 2:
Mailing Address - City:OSSINING
Mailing Address - State:NY
Mailing Address - Zip Code:10562-4423
Mailing Address - Country:US
Mailing Address - Phone:914-582-4177
Mailing Address - Fax:
Practice Address - Street 1:445 N STATE RD STE 2
Practice Address - Street 2:
Practice Address - City:BRIARCLIFF
Practice Address - State:NY
Practice Address - Zip Code:10510-1460
Practice Address - Country:US
Practice Address - Phone:914-582-4177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025699-01103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist